The University of Montana
RiteCare Speech Language & Hearing Clinic
32 Campus Drive
Missoula, MT 59812
Phone: 406-243-2104
Fax: 406-243-2362
Date application received:___________ Initials: _________________________ File # Assigned:___________________ Entered into DB:__________________
Today’s Date:
Contents I. Identifying Informatio n II. Concerns III. School History IV. Previous Testing or Therapy V. Birt h/Medical History VI. Spee ch/Languag e Developmen t VII. Mot or Developme nt VIII. Ho me/Social Environme nt2012-2013
Intensive Aphasia Program
Application for Speech & Language Services
I. Identifying Information
Name of Individual with Aphasia:
Date of Birth:State: Zip: Phone: Work Phone: Whose phone number is it? Cell Phone:
E-mail:
What is the best way to contact you during the day: home phone work phone cell phone e-mail Primary Communication Partner’s Name:
Relationship to Individual with Aphasia:
Person completing this form
Spouse Other, please provide name:
Who referred you to us? (Include name and profession):
Leave the next three lines blank if you are a spouse or family member living in the same home
Your name:
Relationship to Individual with Aphasia:
Your phone: Alternate phone, if applicable: E-mail:
Please carefully read and initial below if you accept the conditions:
By applying to this Intensive Aphasia Program I understand that, if accepted, the individual with aphasia will be seen for treatment during the Intensive Aphasia Program only. It is not guaranteed that the UM RiteCare SLHC can
continue treatment with the individual with aphasia at the end of the Intensive Aphasia Program. I understand that if I want to continue treatment through the UM RiteCare SLHC I may be placed on a waiting list until space is available. I have read and agree to the terms of enrollment in the Intensive Aphasia Program _________ (initials of Individual with Aphasia or legal representative).
II. History of Stroke and Rehabilitation/Therapy Services
Please help us understand the history of your stroke (or brain injury) and the professional services you have received since that event. This information will help us prepare for your first visit with us. Additionally, we will request medical records, but your personal perspective is very important to us. Thank you.
B. Please list the following information – to the best of your ability*:
1. Sequence of medical care and length of stay if you spent time in a hospital, rehab facility and/or skilled nursing facility, or received home care or outpatient services:
2. Services received (i.e., Speech, PT, OT), including when and where:
*(Please attach copies of available reports if you have them, or additional notes that you feel will help us to learn about the individual with aphasia. Thank you.)
II. History of Stroke and Rehabilitation/Therapy Services
C. Current or Most Recent Speech-Language Pathology Services 1. Speech Pathologist:
2. Facility:
Please fill out an “Authorization for Exchange of Confidential Information” formso that we may contact this person.4. In your own words, please describe the individual with aphasia’s communication skills in the following areas or modalities: SPEAKING: LISTENING/UNDERSTANDING: READING: WRITING: THINKING/PROBLEM SOLVING:
5. Does the individual with aphasia use any tools or strategies to assist himself or herself in getting their message across?
6. Are there things that communication partners do to assist the individual with aphasia to communicate more successfully?
III. General Health History
A. Please list other medical conditions and hospitalizations, including date and reason:
B. Are there any other medical concerns? yes no Please specify:
C. Current medications(prescribed and over-the-counter):
Name of Medication Purpose Dosage/Frequency
D. Hearing:
1. Is hearing normal? yes no If NO, does this individual own and wear hearing aids? yes no 2. Date and place of most recent hearing test:
III. General Health History
E. Vision
1. Is sight normal? yes no If NO, does this individual own and wear glasses? yes no 2. Date of most recent eye exam:
Additional Comments:
IV. Education and Work/Employment History
A. Education
1. Highest grade or degree completed:
2. Please indicate below the schools attended:
School Name/Location When? # of Years Degree/Area of Study
B. Employment:
1. Please briefly list employment/work history starting with most recent:
Job Time Period
2. If employed, is the individual with aphasia still working? yes no
3. If the individual with aphasia has stopped working, are there plans to return to work? Has the individual
with aphasia currently, or recently, received vocational support services through an agency?
yes noV. Leisure Activities & Interests:
A. Please help us get to know the individual with aphasia by listing or describing his or her interests, hobbies and daily activities that are currently participated in at home and in the community since the stroke:
B. Are there activities and interests that were participated in before the stroke that the individual with aphasia is no longer doing? Please identify:
C. Are there activities that the individual with aphasia wishes they could resume or begin to participate in now?
