Services

New Patient Forms

Prior to your appointment, the clinic administrative staff will contact you and ask you to download and complete one or more of the following forms.

Forms for New Pediatric Patients

Hearing Clinic Policies Form
Newborn Hearing Evaluation Case History (birth to 3 months old)

Infant Hearing Evaluation Case History (3 months to 6 months old)
Pediatric Hearing Evaluation Case History
Pediatric Cochlear Implant Evaluation Case History

Forms for New Adult Patients

Hearing Clinic Policies Form
Adult Hearing Evaluation Case History

Adult Auditory Processing Disorder Evaluation Case History
Adult Cochlear Implant Evaluation Case History
Adult Vestibular Evaluation Case History

Forms for Pediatric APD Patients

Hearing Clinic Policies Form
C.H.I.L.D. Form for Parent 
C.H.I.L.D. Form for Child 
Children's Home Inventory for Listening Difficulties. This form helps assess the level of difficulty your child is having listening and understanding in different situations at home. If your child is not old enough to fill out the form, fill out the C.H.I.L.D. Form for Parent. If you child is old enough to fill out the form with your help, you can fill out the C.H.I.L.D. Form for Child.

C.H.A.P.S. Form for Your Child's Teachers 
Children's Auditory Performance Scale. This form allows your child's teacher(s) to assess their level of difficulty listening and understanding in the classroom. Please have each of your child's teachers fill out a copy of this form.

S.I.F.T.E.R Form for Your Child's Teachers
Screening Instrument for Targeting Educational Risk in Secondary Students. This form assesses how your child's hearing is impacting their performance in the classroom. Please have each of your child's teachers fill out a copy of this form.