Private Practice Intake and Policies Template

Starting or growing a private practice means building systems that support both excellent clinical care and clear expectations for families. One of the most important systems in any practice is a well-designed intake and policy framework.

The Neuroaffirming Pediatric Speech Therapy Intake & Practice Policy Toolkit is a comprehensive, customizable template designed to help speech-language pathologists streamline their client onboarding process while maintaining neurodiversity-affirming practices.

This toolkit combines clinical intake forms, caregiver questionnaires, and professional practice policies into one cohesive system that can be easily edited and adapted for your own clinic.

Instead of spending hours writing intake forms and policies from scratch, you’ll have a ready-to-use structure that supports clear communication, consistent expectations, and organized documentation.

What’s Included

This toolkit provides a complete intake and policy system for pediatric speech therapy private practices.

Sections included in the template:

Practice Information

• Practice contact details

• Clinic information page

Pediatric Client Intake

• Child information

• Parent/guardian contact information

• Emergency contact details

Communication Profile

• How the child communicates

• Current communication methods

• Successful strategies already in use

Communication Accommodations

• Supports that help the child communicate effectively

• Processing time considerations

• AAC and visual supports

Sensory Profile

• Auditory sensitivities

• Visual sensitivities

• Tactile preferences

• Movement and regulation needs

• Sensory supports that help the child regulate

Strengths & Interests

• Child strengths

• Preferred activities

• Motivators for therapy

Accessibility Needs

• Environmental supports

• Mobility accommodations

• AAC access

• Caregiver presence during sessions

Medical & Developmental Background

• Diagnoses

• Medications

• Allergies

• Previous therapies

School & IEP Information

• School services

• Educational supports

• Related therapies

Therapy Goals

• Parent goals

• Child goals

• Communication challenges

Practice Policies Included

This toolkit also includes expanded policy templates that practices can customize:

• Card on File Policy

• Cancellation Policy

• Late Arrival Policy

• Late Pick-Up Policy

• Attendance Consistency Policy

• Make-Up Session Policy

• Financial Responsibility Policy

• Consent for Services

• Assumption of Risk

• HIPAA Privacy Policy Template

• Photo & Video Release

• Incident Reporting Policy

• Client Dismissal Policy

• Scheduling & Waitlist Policy

These policies help establish clear expectations for families and consistent procedures within your practice.

Who This Toolkit Is For

This template is designed for:

• Speech-language pathologists starting a private practice
• Pediatric private practice owners
• SLPs updating their intake process
• Clinics wanting a more neuroaffirming intake system

Fully Customizable

The template is designed to be fully editable, allowing you to:

• add your practice name and branding
• adjust policies to match your procedures
• remove or add sections as needed
• customize formatting to your clinic style

Why This Toolkit Helps Your Practice

A structured intake and policy system helps:

• create a smoother onboarding process for families
• gather meaningful clinical information before the first visit
• reduce confusion about scheduling and cancellations
• set clear expectations for attendance and communication
• save time when building or updating your practice paperwork

Important Disclaimer

This template is provided for informational purposes and is intended as a customizable resource for speech-language pathology private practices.

It does not constitute legal, financial, or accounting advice and has not been reviewed by an attorney or accountant. Practices are responsible for reviewing and modifying policies to ensure compliance with local, state, and federal regulations.