Adult Case History Form. Cell:

Transcription

1 Department of Communicative Sciences and Disorders 665 Broadway, 9th Floor New York, NY P: F: Adult Case History Form Name: Address: Birth date: Current Age Contact person (name): Address (if different): Date completed Phone: Cell: Gender Relationship: Phone: Cell: Marital Status: Single Married Divorced Widowed #of children: Boys Girls Handedness: Right Left Ambidextrous Is anyone in your family left-handed Primary language/s spoken now 1 st language learned Languages spoken other than English Where did you grow up? Where have you lived as an adult? Highest grade completed Degree(s) If college degree(s), in what field(s)? From what school(s) Occupation(s) (most recent first, include approximate #of years) Current Primary Physician(s) Address Specialty Phone Referred to NYU Speech-Language Pathology and Audiology Department by

2 Please check the statement(s) below that describe your problem. articulation (difficulty pronouncing words or sounds) fluency (stuttering or stammering) use of your voice (hoarseness, weakness, discomfort, strain, pitch, pitch level, etc.) use of language (difficulty finding words or forming sentences, understanding what people say) other Please describe your concerns regarding your speech / voice / language difficulties. How long have you had this concern? Why are you requesting an evaluation at this time? What are your expectations or goals in coming to this clinic? In the time since you have become concerned, has your speech / voice / language changed at all? Please describe. Do your productions change under various conditions? In what situations are you at your best and in which situations do you experience the most difficulty?

3 Please describe any social, emotional, or vocational problems resulting from your speech / voice / language difficulty. Have you made any efforts to improve your speech / voice / language? If so, please describe what you did and what, if any, changes you have noticed. Has your speech / voice / language ever been evaluated? If so, please describe when and where. Please describe the findings of the evaluation. Have you previously received therapy for this concern? When? Where? For how long? Have you been evaluated by a psychiatrist or psychologist? Have you ever been evaluated by a neurologist? If so, what were the results?

4 Did you experience a stroke? Left side of the brain Right side of the brain Head injury? Slow onset of speech/language difficulties? Date of stroke(s) of head injury? Age at time of stroke or head injury? Length of unconsciousness, if any Hospital (acute care) Physician at time of stroke Rehabilitation setting If you had a stroke, describe what happened at the time of the stroke and describe the problems or difficulties experiences soon after the stroke (include communication, body weakness, changes in vision). Do your current difficulties include: Weakness on one side of the body (left or right) Paralysis on one side of the body? (left or right) Loss of vision Dizziness / Fainting / Headaches? Seizures If yes, what was the date of the last seizure Do you wear glasses? Wear a hearing aid? left ear right ear When and where was your hearing most recently evaluated? Have you experienced any changes in mood, personality, or ability to care for yourself, etc?

5 Please list any medications you are currently taking and state the reason why. Have you had a CT or MRI head scan? When and where was the most recent scan? Prior to the onset of your speech / voice / language difficulties was there a history of any of the following? Communication Disorder Yes No Describe Memory Impairment Yes No Describe Head Injury Yes No Describe Seizure Disorder Yes No Describe Brain Surgery Yes No Describe Previous Stroke Yes No Describe. Clinical Depression Yes No Describe Psychiatric Problems Yes No Describe Alcohol Abuse / Problems Yes No Describe Substance Abuse Yes No Describe Dementia Yes No Describe Other Neurological Disease Yes No Describe Other Major Illness Yes No Describe (for example, heart disease, high blood pressure, diabetes)

6 Please provide some family and social information. List important family members (for example, names, ages, & location of children), friends, or pets What are some major accomplishments or highlights of your life? Describe hobbies and other topics or activities of interest. Does any other member of you family have a speech / voice / language/ hearing problem or learning disability? Please state who and describe the problem. Please describe any additional information you feel would be helpful to us in evaluating your problem.

7 Name of person who assisted in completing this form (if any) Relationship Client Signature Date Signature of assistant / witness Date

8 Department of Communicative Sciences and Disorders 665 Broadway, 9 th Floor New York, NY P: F: Attendance and Payment Policies Due to the increasing demand for services and our responsibility to train graduate students, the clinic must uphold the following policy: Attendance at evaluations: Consent and intake forms and payment must be received by the clinic two weeks before an appointment will be scheduled. Appointments for evaluation must be canceled one week in advance and will be rescheduled at the discretion of the clinic director. Evaluation appointments cancelled within 48 hours of the scheduled evaluation are nonrefundable. Attendance at treatment sessions: To report an absence, please call the main desk at Please make every attempt to attend each scheduled session and to arrive on time so that you or your child can make the maximum progress. If you must be absent and know ahead of time, please advise your supervising clinician as soon as possible. Make-up for sessions cancelled by the client are scheduled at the discretion of the supervisor. Every effort will be made to make up sessions canceled by our clinicians. For absences greater than two weeks in duration, your supervising clinician may ask you to consider enrolling for the following semester depending on the impact of your absence on your or your child s treatment and on the training of our student clinicians. If you have to cancel your appointment with less than 24 hours notice, the session will be counted as an unexcused absence unless there has been an emergency, illness or other extenuating circumstance. If a client fails to attend an appointment without notifying the clinician, this will also be counted as an unexcused absence. 665 Broadway, 9 th Floor New York, New York 10012

9 Upon having two unexcused absences, clients will be notified of possible termination. After three unexcused absences, services will be terminated and the client will be provided with the names of other facilities for treatment. Tardiness: If the client arrives more than 15 minutes after his/her scheduled appointment, the session will be held at the discretion of the supervising clinician. If the client arrives late for more than two sessions, the supervising clinician will suggest that the client schedule the session at an alternate time or wait until the following semester for a time slot more conducive to the client s schedule. Upon three late arrivals, clients will be notified of possible termination. Safety: Children 17 years of age and under must be accompanied to their treatment session by a parent or guardian. The parent or guardian must remain in the clinic throughout the treatment session. Family, caregivers or home health aides accompanying adult clients must remain in the clinic throughout the treatment session. Failure to do so will result in discharge from treatment. Session observations: You may observe all sessions conducted with the student clinician assigned to your child/family member/person you care for. We encourage you to observe, ask questions and reinforce treatment strategies at home. I have read and agree to the terms and conditions of the attendance policy. Signature of client or parent/guardian: Date: 665 Broadway, 9 th Floor New York, New York 10012

10 Payment Agreement The clinic does not accept insurance. After payment is made, we will provide copies of documentation for you to submit to your insurance carrier, at your request. Fees for all treatment services are billed at the start of each semester and are due by mid-semester. Clients who have not paid their bill in full by the end of the semester will not be scheduled for further sessions. If you require a copy of your most recent invoice, please alert the receptionist. If you are experiencing financial hardship, contact the Clinic Director, Iris Fishman, at or irf2007@nyu.edu. Invoices are payable by credit card, personal check or money order. Fees are payable to NYU. I have read and agree to pay the NYU Speech-Language-Hearing Clinic any and all charges incurred by visits and services rendered. Signature of client or parent/guardian: Date: Contact of person responsible for bill payment (if different than above): Name: Address: Phone: rev. 01/29/ Broadway, 9 th Floor New York, New York 10012

11 Department of Communicative Sciences and Disorders 665 Broadway, 9 th Floor New York, NY P: F: Client Name: Date: Client Consent for Evaluation and Treatment by Student Clinicians and Audio- Visual Recording The Speech-Language-Hearing Disorders Clinic is a facility at New York University, which provides professional services to the public in speech, language, cognitive, voice, fluency and hearing evaluation and treatment. In addition to its service function, it is an integral part of the graduate teaching programs of the University. Substantially, all services at the clinic are performed by graduate student interns in the Department of Speech-Language Pathology and Audiology, under the supervision of ASHA certified and NYS licensed Speech-Language Pathologists. Client sessions are conducted and observed by graduate students and are recorded on DVD, VHS, audiotape and/or digital recorders for future discussions by graduate students and their instructors/clinical supervisors. In order for the Speech-Language-Hearing Disorders Clinic to be able to provide professional services, it is necessary that the client be willing to cooperate with the educational and research activities of the clinic and department in the ways indicated below. Clients may be assured that such activities will enhance the quality of the services provided. I have read the above statements, and I: 1. Grant permission for The New York University Speech-Language-Hearing Disorders Clinic to evaluate and/or treat the above named client. 2. Agree that services may be provided to the above-named client by graduate student interns, faculty, or clinical associates. 3. Agree that except under circumstances requiring absolute privacy, interviews and other sessions in which the above-named client participates in may be observed by graduate students and departmental faculty and may be recorded on DVD, VHS, audiotape or digital medium and that such media may be used in connection with the teaching programs of the department. If you have any questions about this statement, please ask before signing. By signing below, I agree that I have reviewed and understand the information above: Client / Parent / Guardian Signature Relationship to client Print Name Services will not be provided at the New York University Speech-Language-Hearing Disorders Clinic without this form being signed Broadway, 9 th Floor New York, New York 10012

12 S P E E C H - L AN G U AG E - H E AR I N G C L I N I C: INTAKE FORM Client s Name: Date of Birth: Age: Department of Communicative Sciences and Disorders 665 Broadway, 9 th Floor New York, NY P: F: New Client / Returning Client Referred By: CONTACT INFORMATION Client/Parent or guardian name: Address: City: State: Zip: Home Phone: Cell Phone: Other Phone: Primary care physician: Phone: Fax: DIAGNOSTIC HISTORY Past diagnosis: Has the client received an evaluation/therapy before? If yes, what type? Speech / Occupational / Neurological When: Where: Date of last evaluation: Please send a copy of the evaluation. Yes / No Has the client had a hearing evaluation? Yes / No When: Where: Any history of the following: Middle ear infections Tubes in ears Asthma Allergies Seizures Other Is the client taking any medications? Yes / No If yes, please describe: LANGUAGES SPOKEN Client s primary language: Secondary language(s) spoken: Parent s primary language: 665 Broadway, 9 th Floor New York, New York 10012

13 EMERGENCY CONTACT INFORMATION Name: Relationship: Address: City: State: Zip: Home Phone: Cell Phone: Other Phone: Name: Relationship: Address: City: State: Zip: Home Phone: Cell Phone: Other Phone: SERVICES SOUGHT Aphasia Fluency Voice Disorder (i.e. hoarseness) Other: Accent Modification Articulation Language SCHEDULING The clinic is open Monday- Thursday 11 am - 7pm. Please indicate availability below: Monday Tuesday Wednesday Thursday Clients are scheduled on a first come, first served basis during each academic semester. Please be sure to provide us with as many scheduling options as possible. Clients may be placed on a waiting list for services.