Department of Communication Disorders and Sciences

______Language, Speech and HearingCenter

College of Health and Human Development

Adult Information Form

Thank you for your interest in our clinical services. To help us better serve you, please provide us with the information requested below. Please be assured that this information will be held confidential, and is necessary for the Center staff to determine appropriate evaluation and therapy services. The completed form may be mailed or faxed to us at:

18111 Nordhoff Street

Monterey Hall, Room 100

Northridge, CA91330-8288

818-677-2856; FAX 818-677-5952

E-mail:

Client Name: ______Date: ______

Date of Birth: ___/____/____Age: ______Sex:  M F

Street Address: ______

City: ______State: ______Zip Code: ______

Phone Numbers: Home: ______Cell: ______

Work: ______

E-mail: ______

Present Occupation: ______

Highest Level of Education Completed: ______

School Presently Attending, if applicable: ______

Place of Birth: ______

Native Language: ______Other Languages Spoken: ______

How did you find out about this Center?______

Name of person filling out questionnaire: ______

Relationship to client, if other than client: ______

Services Requested:  Speech-Language Evaluation

 Speech-Language Therapy

 Other ______

Monterey Hall. 18111 Nordhoff Street. Northridge, CA91330-8288.

(818) 677-2856 FAX (818) 677-5952

GENERAL INFORMATION

Describe the speech-language problem: ______

______

What do you think may have caused the problem? ______

______

Has the problem changed since it was first noticed (e.g. improved or worsened)? ______

______

Have you had a previous speech-language evaluation?  Yes  No

If yes, where and when? ______

If yes, what were the recommendations? ______

Have you had previous speech-language therapy?  Yes  No

Is yes, where and when? ______

Have you seen any other specialists (physicians, audiologists, psychologists, neurologists, etc)? Yes  No

If yes, indicate the type of specialist, when you were seen, and the specialist’s

conclusions or suggestions. ______

______

Medical History

Do you have or have you had any eating or swallowing difficulties?  Yes  No

If yes, please describe:

Do you have or have you had any problems with your breathing? Yes  No

If yes, please describe:

Do you have or have you had any problems with vocal quality? Yes  No

If yes, please describe:

Please list any serious injuries, high fevers, seizures, hospitalizations, surgeries, neurological events or diseases, physical handicaps, or other medical information that you think may be relevant. Please give dates or approximate ages for each event.

______

Are you presently under the care of a specialist (e.g. neurologist, an ear- nose- and throat

specialist (ENT), physiatrist (rehab M.D.), physical therapist, psychologist, or other? Yes  No

If yes, please list each specialist’s name, address, and type of specialty:

Please complete this chart regarding any medication that you arecurrently taking.

Medication / Dosage / Frequency of Administration / Reason for Meds

Please describe any problems with your teeth, tongue, mouth, ears, nose, or throat:

______

Are you right- handed or left- handed? ______

Describe any vision or hearing problems you may have: ______

______

FAMILY, SOCIAL AND EDUCATION INFORMATION

Do you have, or have you ever had, any school or learning problems? If so, please describe:

______

Do you have, or have you ever had, problems with memory or thinking? Yes  No

If yes, please describe:

Is there anything else you would like us to know? ______

______

We thank you for your time, and the care with which you filled out this form. This intake form will be reviewed by our professional licensed staff for appropriateness for this clinical setting, then you will be contacted by our clinic office staff. While we strive to provide all requestors with the therapy services that they desire, we would like you to keep two things in mind:

All clients, regardless of where they receive speech-language services, must have a current speech and language assessment prior to the start of any therapy program.
We cannot make any promises about placement in therapy here in our Center until we have completed our assessment process.

We appreciate your patronage, and look forward to helping you and your loved ones.

- The Professionals, Student Trainees, and Staff of the Language, Speech and HearingCenter

Monterey Hall. 18111 Nordhoff Street. Northridge, CA91330-8288.

(818) 677-2856 FAX (818) 677-5952