General Information
Name of the person completing this application:
*
Relationship to client:
*
Please Select
Self
Spouse
Significant Other
Friend
Parent
Child
Sibling
Other
Phone Number:
*
Please enter a valid phone number.
Format: 000-000-0000.
Email:
*
example@example.com
How did you hear about Atlas Aphasia Center?
*
Please note: Atlas only provides services in Washington state
Client Information
Client's Full Name:
*
First Name
Last Name
Nickname or preferred name:
Date of Birth:
*
/
Month
/
Day
Year
Date of Aphasia Onset:
*
/
Month
/
Day
Year
Cause of Aphasia:
*
Stroke
Traumatic Brain Injury
Moyamoya
Progressive Neurological Disease
Tumor
Other
Hospitals/clinics for treatment and approximate dates:
*
Sex assigned at birth?
Please Select
Male
Female
Intersex
Prefer not to say
Used for grants and research data
Gender Identity:
*
Please Select
Male
Female
Non-binary
Transgender
Genderqueer
Other
Prefer not to say
Used for grants and research data
Racial/Ethnic Identity (select all that apply):
*
African American or Black
American Indian or Alaska Native
Asian or Asian American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Other
Estimated Annual Household Income
*
Please Select
Less than $25,000
$25,000-$49,000
$50,000-$75,000
Over $75,000
Decline to State
Used for grants and research data
Client's Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Phone Number:
Please enter a valid phone number.
Format: 000-000-0000.
Client's Email:
example@example.com
Emergency Contact Name
Emergency Contact Phone Number
Medical Information
Handedness:
*
Right hand dominant
Left hand dominant
Ambidexterous
Other
Hemiparesis/paralysis:
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No weakness
Right-sided weakness
Left-sided weakness
Both sides are weak
Other
Currently using a cane or walker?
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Yes
No
Sometimes
Currently using a wheelchair?
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Yes
No
Sometimes
If coming to the office – is the client independent with transfers (sit-to-stand, bathroom)?
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Yes
No
Other
Currently driving?
Yes
No
Glasses?
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No glasses
Reading
Distance
Other
Hearing aids?
*
Yes
No
Other
Special Diet?
*
No
Yes (please describe)
Name of Physiatrist and/or Neurologist:
Names/specialties of other relevant physicians:
Please list any longstanding health conditions or medical issues:
*
Please list current medications, dosage, and frequency:
*
In case of medical emergency
Please list all allergies (latex, food, medications, other):
*
Other speech therapy services:
*
Previously
Currently
Have not received any speech therapy
Please describe other speech therapy (dates, location, therapist):
Currently receiving other therapies?
Physical therapy
Occupational therapy
Recreation therapy
Vision therapy
Mental health/counseling
Other
Social Contacts
Relationship Status:
*
Single
Separated
Married
Divorced
Partnered
Widowed
Other
Name of partner, spouse, or significant other:
List immediate family - name, relationship, and city of residence:
List pets - type of animal and name:
Before aphasia onset, who did the client talk to more than 1x per week?
*
Over the past week, who has the client talked to more than once?
*
Education/Employment History
Highest grade level completed?
*
Please Select
Less than high school
High school diploma or GED
Some college
Associate's degree
Bachelor's degree
Master's degree
Doctoral or professional degree
Employed at the time of aphasia onset?
*
No
Yes (job title/place of work?)
Previous occupations/job titles:
*
Is returning to work a goal?
*
Yes, ASAP
Yes, but it's a long-term goal
Yes, but in a different role or capacity
No, not a goal at this time
Other
Language/Communication Skills
What was the client's first language?
*
English
Other
Is English currently the primary language for daily interactions?
*
Yes
No
Yes, along with another language
Languages spoken, contexts used, and proficiency levels:
Current level of verbal expression (talking):
*
Unable
Words
Phrases
Sentences
Not sure
Explain or provide examples of verbal expression (talking):
Current level of comprehension (understanding):
*
Does not appear to understand
Understands pointing, gestures, facial expressions
Understands single words
Understands conversations
Understands questions
Understands lengthy/complex statements and questions
Not sure
Explain or provide examples of comprehension (understanding):
Current level of reading:
*
Unable
Reads single words
Reads sentences
Reads paragraphs
Reads books or newspapers
Not sure
Explain or provide examples of reading:
Current level of writing:
*
Unable
Writes name
Writes single words
Writes sentences
Writes paragraphs
Not sure
Explain or provide examples of writing:
Any communication, reading, or writing difficulties prior to onset of aphasia?
*
Hobbies/Interests
Hobbies/Interests:
*
Rows
Before Aphasia
Currently
Reading newspapers, magazines, books
Listening to audiobooks, podcasts
Using social media (Facebook, Instagram, etc.)
Watching TV, movies
Cooking/baking
Playing videogames
Playing sports
Exercising
Visiting family, friends
Attending religious services
Gardening
Drawing, painting, sketching
Photography
Traveling
Volunteering
Other
Topics the client is interested in:
Topics that should be avoided:
Communication Style
Please check all that describe the client's communication BEFORE aphasia:
*
Talkative
Spoke clearly
Quiet
Witty
Spoke slowly
Told lots of jokes
A fast talker
Told lots of stories
Argumentative
A good listener
Reserved
A large vocabulary
Used hands a lot
Repetitive
Mumbler
Got off subject
Other description of the client's communication BEFORE aphasia:
Therapy / Scheduling
What days are preferred for speech therapy?
*
Monday
Tuesday
Wednesday
Thursday
What time of day is preferred for speech therapy?
*
Mornings
Afternoons
Either is fine
Varies by day
Schedule limitations or conflicts:
What are some language-related goals for therapy?
Optional: We have listed some items below. Please check any boxes that represent current language-related goals.
Social goals:
Introduce self/others
Initiate conversation
Request actions/objects
Answer questions
Tell stories/jokes
Provide instructions
Give messages
Take part in longer/more complex discussions
Participate in community/family events (parties, etc.)
Other
Technology goals:
Make phone calls
Make video calls (FaceTime, Zoom, Hangouts, Skype)
Read/respond to email
Read/respond to texts
Browse the internet
Online shopping
Use voice control (Siri, Alexa)
Use iPad/other tablet
Use Google Maps or Apple Maps
Other
Financial goals:
Check and pay bills
Read bank statements
Pay rent/mortgage
Use cash
Use credit cards
Use an ATM
Other
Daily Activity goals:
Follow a recipe
Follow instructions for household appliances
Read/write a shopping list
Care for pets
Make/cancel plans with friends
Use public transportation
Drive a car
Other
Medical goals:
Describe symptoms
Make/cancel appointments
Understand instructions/explanations
Complete medical forms
Follow instructions on medicine labels
Other
Leisure Activity goals:
Read newspapers, magazines, books
Read menus/order food
Read/write letters, cards, other mail
Listen to audiobooks/podcasts
Watch/understand TV shows
Watch sports, listen to sports commentary
Play cards or board games
Do crossword puzzles
Book and buy tickets to events
Read/sing at religious services
Other
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