Department of Communicative Sciences and Disorders 665 Broadway, 9 th Floor New York, NY 10012 P: 212-998-5230 F: 212-995-4356 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 212 998 5230. 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 212 998 5230 212 995 4356 fax www.steinhardt.nyu.edu/csd
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 212 998 5230 212 995 4356 fax www.steinhardt.nyu.edu/csd
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 212-998-5230 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: Email: Phone: rev. 01/29/2015 665 Broadway, 9 th Floor New York, New York 10012 212 998 5230 212 995 4356 fax www.steinhardt.nyu.edu/csd
Department of Communicative Sciences and Disorders 665 Broadway, 9 th Floor New York, NY 10012 P: 212-998-5230 F: 212-995-4356 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.. 665 Broadway, 9 th Floor New York, New York 10012 212 998 5230 212 995 4356 fax www.steinhardt.nyu.edu/csd
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 10012 New York, NY 10012 P: 212-998-5230 F: 212-995-4356 New Client / Returning Client Referred By: CONTACT INFORMATION Client/Parent or guardian name: Address: City: State: Zip: Home Phone: Cell Phone: Other Phone: Email: 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 212 998 5230 212 995 4356 fax www.steinhardt.nyu.edu/csd
EMERGENCY CONTACT INFORMATION Name: Relationship: Address: City: State: Zip: Home Phone: Cell Phone: Other Phone: E-mail: Name: Relationship: Address: City: State: Zip: Home Phone: Cell Phone: Other Phone: E-mail: 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.
SPEECH-LANGUAGE-HEARING DISORDERS CLINIC Child Case History Form Date Child s Name M F Age Address Birth date Parent/Guardian s Name Telephone: (Home) (Work) (Cell) Email: Address Department of Communicative Sciences and Disorders 665 Broadway, 9 th Floor 10012 New York, NY 10012 P: 212-998-5230 F: 212-995-4356 Parent/Guardian s Name Telephone: (Home) (Work) (Cell) Email: Address Person responsible for payment Telephone: (Home) (Work) (Cell) Email: Address (if different from above) How did you hear about us? Who is filling out this questionnaire? Relationship to child Describe your child s speech-language problem When did you first notice the problem? When did you become concerned? Who have you seen regarding this problem? (Doctor, Psychologist, etc.): 1
How has the problem changed since you first noticed it? What has been done about it? Has this helped? What do you think caused the problem? Family Information Parent s occupation Last grade completed in school Parent s occupation Last grade completed in school Siblings Age Age Language(s) spoken at home Are there any family members or relatives who have or had speech, language or hearing problems? Pregnancy, Birth History and Early Development This child s birth order : Is the child adopted? During pregnancy with this child, did mother have any Illness? Take medication? If so, explain: Was labor at all problematic? Explain: Was the child s birth at all problematic? Explain: 2
Did the child have any trouble breathing after birth? Was the child kept in an incubator? Explain: Was feeding at all a problem? If so, explain: Bottle Fed? Breast Fed? Age weaned from breast? Age weaned from bottle? At what age did child drink from an open cup, independently? At what age did child finger feed self? Able to eat with a spoon? Does the child have any problems eating now? Is she/he a picky eater? If so, explain: When did the child first get teeth? If so, explain: Has the child had dental problems? Dentist s name and telephone number? Was the child very active as a baby? When did the child learn to: sit alone? feed him/herself? dress him/herself? walk independently? How well does the child: walk? 3
run? throw a ball? If the child has problems with any of the above motor activities, explain: Is the child toilet trained? If so, at what age was he/she toilet trained? Does the child wet the bed now? How often? What hand does your child use to: eat? draw? write? throw a ball? How would you describe your child s current physical development? Medical History Pediatrician s name and telephone number Has the child ever been hospitalized since birth? age If so, please give reason and Has the child had any serious illnesses or accidents? If so, explain: Has the child ever fainted? Had convulsions? If so, explain: Ear infections? How long? How does the child alert you when he/she is suffering from middle ear pain? When was your child s most recent hearing test? 4
What was the result of the testing? (Please provide test results if available) Please describe any concerns you may have regarding your child s hearing? Does the child have any problems seeing? Wears glasses? Does the child have any trouble sleeping at night? Waking up in the morning? If so, explain: Is the child presently being seen by a pediatrician? ENT (otolaryngologist)? Psychologist? Speech therapist? Neurologist? Physical therapist? Occupational therapist? If so, explain (please provide name and telephone number of this professional): Speech History Was the child very quiet as a baby? Did she/he coo? babble? Did the child cry excessively as a baby? When did he/she speak single words (other than mama or dada )? What were the child s first few words? Approximately how many words did the child have at 18 months? When did he/she begin to combine words (two-word sentences)? Does he/she use gestures? (Give examples if possible) 5
If the child talks now, can you understand? Can other family members Can strangers? How do you think the child feels about his/her speech? Do you think the child stutters or stammers? Does the child use complete sentences? If not, describe how he/she speaks: Does the child have difficulty pronouncing words? If so, Explain: Does your child follow your directions? Please provide an example. Has the child s speech development been different from other children you have known? If so, explain: Reading and Writing (If age appropriate please complete) Has the child had any problems learning to read? Learning to write? If so, explain: 6
Do you read to your child? Does your child enjoy being read to? Does the child know his/her alphabet? Can the child write well for his/her age? If not, explain: Math Has the child had difficulty learning math? If so, explain: Does the child find rote learning or problem solving easier? Cognitive Development Which toys did your child pay with at age 12-18 months? 24-36 months? Does the child seem to learn quickly? slowly? Is he/she an average learner? Does the child have difficulty making judgments? Solving everyday problems? Reasoning? If so, explain: Educational History Where does your child attend school? What grade does your child attend? Has the child had any problems in school? making friends? If so, explain: Has his/her teachers had any complaints? If so, explain: 7
Is there anything else we should know about your child that is not asked here? 8