Clinic Intake Form

* = required field

Some content may be updated based on selection

NCCU Speech and Hearing Clinic Intake Form

Since 1976, the Department of Communication Sciences and Disorders has operated the Speech, Language, and Hearing Clinic at North Carolina Central University. It is a full-service campus clinic where graduate students in training to become licensed speech-language pathologists provide services. They provide services under the direct supervision of a licensed speech-language pathologist certified by the American Speech-Language-Hearing Association.

Services are provided free of charge to individuals of all ages, toddlers through senior citizens, in individual or group sessions. Services include evaluations and treatment to address speech, language, hearing, and assistive needs. The clinic provides services to diverse populations through our bilingual (Spanish, Chinese, and English) and specialty clinics. Our services include:

Speech, language, and hearing screenings to identify children and adults who may be at risk for a communication disorder
Speech, language, and hearing evaluations to identify and describe a person’s communication problem, hearing issues, or voice concern
Children and adults with diagnosed speech, language or hearing problems can receive treatment at the clinic. The following are examples of issues we address:
- Aphasia
- Right hemisphere damage
- Traumatic brain injury
- Voice disorders
- Swallowing disorders
- Delayed language development
- Speech sound disorders
- Motor speech disorders
- Fluency disorders (stuttering)
- Augmentative/alternative communication
Individuals may choose to receive elective services such as accent modification or transgender voice services.

The NCCU Speech, Language, and Hearing Clinic is accessible to individuals with disabilities, including those using wheelchairs. The clinic does not discriminate in the delivery of services for any reason, including race, color, sex, age, gender, religion, creed, national origin, sexual orientation, veteran status, or disability.

Patient/Client Information

Patient/Client Name

Date of Birth

Age

Home Phone

Mobile Phone

Email Address

Address

City

State

Zip

Gender

Preferred Pronouns

Preferred Language

School (if applicable)

Grade

If you are not the client, please provide your name and your relationship to the client:

Please list both days and times that you are available for sessions (Monday through Friday):

Reason for referral: Please describe your communication, cognition and/or swallowing difficulty.

Have you been seen by a speech-language pathologist before?

If yes, please provide any information you have regarding dates of service, location of service, name of the speech-language pathologist, diagnosis and/or goals of therapy.

Please provide any pertinent medical history related to your communication, cognition or swallowing difficulty:

Please indicate any physical limitations and/or accommodations needed in the clinic (e.g., sound amplification or wheelchair access):

How did you hear about the NCCU Speech-Language Hearing Clinic?

Caregiver/Parent Information

Caregiver/Parent Name

Relationship to Client

Email Address

Phone Number

Secondary Phone Number

Address

City

State

Zip

Please wait for files to finish uploading

Recaptcha response