Atlas Aphasia Center: Application

General Information
Name of the person completing this application:*
Relationship to client:*
Phone Number:*
Please enter a valid phone number.
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:*

StrokeTraumatic Brain InjuryMoyamoyaProgressive Neurological DiseaseTumorOther
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):*

African American or BlackAmerican Indian or Alaska NativeAsian or Asian AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOther
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.
Client's Email:
example@example.com
Emergency Contact Name
Emergency Contact Phone Number
Medical Information
Handedness:*

Right hand dominantLeft hand dominantAmbidexterousOther
Hemiparesis/paralysis:*

No weaknessRight-sided weaknessLeft-sided weaknessBoth sides are weakOther
Currently using a cane or walker?*

YesNoSometimes
Currently using a wheelchair?*

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

YesNoOther
Currently driving?

YesNo
Glasses?*

No glassesReadingDistanceOther
Hearing aids?*

YesNoOther
Special Diet?*

NoYes (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:*

PreviouslyCurrentlyHave not received any speech therapy
Please describe other speech therapy (dates, location, therapist):
Currently receiving other therapies?

Physical therapyOccupational therapyRecreation therapyVision therapyMental health/counselingOther
Social Contacts
Relationship Status:*

SingleSeparatedMarriedDivorcedPartneredWidowedOther
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?*

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

Yes, ASAPYes, but it's a long-term goalYes, but in a different role or capacityNo, not a goal at this timeOther
Language/Communication Skills
What was the client's first language?*

EnglishOther
Is English currently the primary language for daily interactions?*

YesNoYes, along with another language
Languages spoken, contexts used, and proficiency levels:
Current level of verbal expression (talking):*

UnableWordsPhrasesSentencesNot sure
Explain or provide examples of verbal expression (talking):
Current level of comprehension (understanding):*

Does not appear to understandUnderstands pointing, gestures, facial expressionsUnderstands single wordsUnderstands conversationsUnderstands questionsUnderstands lengthy/complex statements and questionsNot sure
Explain or provide examples of comprehension (understanding):
Current level of reading:*

UnableReads single wordsReads sentencesReads paragraphsReads books or newspapersNot sure
Explain or provide examples of reading:
Current level of writing:*

UnableWrites nameWrites single wordsWrites sentencesWrites paragraphsNot 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:*

TalkativeSpoke clearlyQuietWittySpoke slowlyTold lots of jokesA fast talkerTold lots of storiesArgumentativeA good listenerReservedA large vocabularyUsed hands a lotRepetitiveMumblerGot off subject
Other description of the client's communication BEFORE aphasia:
Therapy / Scheduling
What days are preferred for speech therapy?*

MondayTuesdayWednesdayThursday
What time of day is preferred for speech therapy?*

MorningsAfternoonsEither is fineVaries 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/othersInitiate conversationRequest actions/objectsAnswer questionsTell stories/jokesProvide instructionsGive messagesTake part in longer/more complex discussionsParticipate in community/family events (parties, etc.)Other
Technology goals:

Make phone callsMake video calls (FaceTime, Zoom, Hangouts, Skype)Read/respond to emailRead/respond to textsBrowse the internetOnline shoppingUse voice control (Siri, Alexa)Use iPad/other tabletUse Google Maps or Apple MapsOther
Financial goals:

Check and pay billsRead bank statementsPay rent/mortgageUse cashUse credit cardsUse an ATMOther
Daily Activity goals:

Follow a recipeFollow instructions for household appliancesRead/write a shopping listCare for petsMake/cancel plans with friendsUse public transportationDrive a carOther
Medical goals:

Describe symptomsMake/cancel appointmentsUnderstand instructions/explanationsComplete medical formsFollow instructions on medicine labelsOther
Leisure Activity goals:

Read newspapers, magazines, booksRead menus/order foodRead/write letters, cards, other mailListen to audiobooks/podcastsWatch/understand TV showsWatch sports, listen to sports commentaryPlay cards or board gamesDo crossword puzzlesBook and buy tickets to eventsRead/sing at religious servicesOther
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.