Client Application

Welcome to the Ludden Speech and Language Clinic. Thank you for inquiring about our services. In order to submit an application for services, please completely review the Ludden Clinic Client Handbook (PDF) and complete the case history, diagnostic request, and registration forms.

Saint Xavier University
Ludden Speech and Language Clinic
3700 W. 103rd Street
Chicago, IL 60655

Please mail the following forms:

1. The following forms must be filled out completely. Be sure to include a description of speech and language difficulties.
   • 17 years and older: Adult Case History (PDF)
   • 16 years and under: Child Case History (PDF)
2. A diagnostic request form so that an evaluation may be arranged at a mutually agreeable time.
   • Diagnostic Request Form (PDF)
3. A completed Registration Form (PDF).
   • Please be sure to review the Notice of Privacy Policy and Insurance Information Practices (PDF) as you complete your registration.

An optional Consent to Obtain or Furnish Patient Information Form (PDF) is also available, if you choose to fill out and send in.

Once the Clinic receives your completed paperwork and there is an opening in the clinic schedule, you will be contacted to arrange a time for the evaluation. If you have any questions or concerns, please feel free to contact the Clinic at 773-298-3571.

We look forward to serving you and your family.

Kathy Rohan
Director, Clinic Operations
Phone: 773-298-3571
Email: luddenclinicFREESXU