Please submit this form prior to our first meeting.

At the bottom of the form you’ll also have an opportunity to upload copies of any previous evaluations.

Please describe your child’s initial and current disfluency patterns (check all that apply)

Please describe your child’s initial and current physical behaviors observed during speech (check all that apply)

Please describe your child’s initial and current reactions to his/her disfluencies (check all that apply)

At what age did your child...? (e.g. 6 months, 10 months, etc.)

List all illnesses, injuries, operations, etc.

Does your child receive:

Family history of stuttering
(It is helpful to ask relatives and your spouse about a possible history of stuttering.)

MOTHER

FATHER

OTHER FAMILY MEMBERS

CHILDREN

Compared to other children, describe your child:
(None: 1-2 / Slightly: 3-4 / Moderately: 5-7 / Highly: 8-10)

Compared to other children, generally how fearful is your child?
(None: 1-2 / Slightly: 3-4 / Moderately: 5-7 / Highly: 8-10)

POLICY: All clients have a right to privacy. Confidentiality of clinical information will be maintained at all times during treatment and after the client is discharged from treatment. All clients have these rights under the Health Insurance Portability & Accountability Act of 1996 (HIPPA).

PROCEDURES:

1. Clinical information is kept in a private location, without public access.

2. The speech pathologist, her graduate assistants and office personnel are the only persons with
access to clinical records.

3. Clinical information is kept out of view to a casual observer.

4. Clinical reports are released to third parties only with written consent of the client. In the case of
a minor, written consent is obtained from a parent or legal guardian.

5. Clinical information is shared with other professionals by phone only with consent of the client. In the case of a minor, consent for phone contact with outside professionals is obtained from a parent or legal guardian.

6. At no time are clients discussed with outside parties without written consent of the client. In the case of a minor, written consent is obtained from a parent or legal guardian.

7. In cases where photography or videotaping is used, written permission to photograph or videotape is obtained from the client. In the case of a minor, written consent for phone contact with outside professionals is obtained from a parent or legal guardian.

8. Computer files containing clinical information are kept in one of two places:

A. Clinical computer files are stored on the main computer by speech pathologist, graduate assistants and office personnel. Access to the computer is protected by a password. No identifying information of the patient is stored on graduate assistant files

B. In cases where reports are written at a location other than the speech therapy office, files are stored on a disk, which is kept on the person of the speech pathologist and/or graduate assistant. No identifying information is stored on graduate assistant files

9. Client records are not faxed to another location without written permission from the client. In the case of a minor, written consent is obtained from a parent or legal guardian.

10. A copy of these policies and procedures will be shared with clients at the time of admission or at any time that changes are made to the policy.