Atlas Aphasia Center: Application

General Information
Name of the person completing this application:
Relationship to client:
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 NameLast Name
Nickname or preferred name:
Date of Birth:

MonthDayYear
Date of Aphasia Onset:

MonthDayYear
Cause of Aphasia:

Other
Hospitals/clinics for treatment and approximate dates:
Sex assigned at birth?
Used for grants and research data
Gender Identity:
Used for grants and research data
Racial/Ethnic Identity (select all that apply):

Other
Estimated Annual Household Income
Used for grants and research data
Client's Address:

Street Address

Street Address Line 2

CityState / 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:

Other
Hemiparesis/paralysis:

Other
Currently using a cane or walker?

Sometimes
Currently using a wheelchair?

Sometimes
If coming to the office – is the client independent with transfers (sit-to-stand, bathroom)?

Other
Currently driving?
Glasses?

Other
Hearing aids?
Special Diet?

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:
Please describe other speech therapy (dates, location, therapist):
Currently receiving other therapies?

Other
Social Contacts
Relationship Status:

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?
Employed at the time of aphasia onset?

Yes (job title/place of work?)
Previous occupations/job titles:
Is returning to work a goal?

Other
Language/Communication Skills
What was the client's first language?

Other
Is English currently the primary language for daily interactions?

Yes, along with another language
Languages spoken, contexts used, and proficiency levels:
Current level of verbal expression (talking):
Explain or provide examples of verbal expression (talking):
Current level of comprehension (understanding):
Explain or provide examples of comprehension (understanding):
Current level of reading:
Explain or provide examples of reading:
Current level of writing:
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:
Other description of the client's communication BEFORE aphasia:
Therapy / Scheduling
What type of therapy are you interested in?
What days are preferred for speech therapy?
What time of day is preferred for speech therapy?

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:

Other
Technology goals:

Other
Financial goals:

Other
Daily Activity goals:

Other
Medical goals:

Other
Leisure Activity goals:

Other
Should be Empty:

General Information

Please note: Atlas only provides services in Washington state

Client Information

Medical Information

Social Contacts

Education/Employment History

Language/Communication Skills

Hobbies/Interests

Communication Style

Therapy / Scheduling

Optional: We have listed some items below. Please check any boxes that represent current language-related goals.