Forms

INSTRUCTIONS FOR USING HUSHMAIL

You will receive an email from Hushmail with forms attached.  You will be given a choice to log in to Hushmail using Google, Microsoft, or Apple.  Check your spam if you do not receive the email as expected.  If you have previously logged in to Hushmail using a passphrase, you must continue to use the same passphrase moving forward.

NEW CLIENT FORMS

ALL CLIENTS SHOULD COMPLETE THE FOLLOWING:

• Client Information Form (PDF) – please sign
• Notice of Privacy Practices (PDF)
• Client Intake Form (PDF) – please sign
• Authorization for Disclosure of Protected Health Information (PDF) – please sign
• Telepractice Consent (PDF)
• Email Consent (PDF)
• Communication Permissions (PDF) – please sign

AUDIOLOGY FORMS

PATIENTS TO BE SEEN FOR EVALUATION OF HEARING OR AUDITORY PROCESSING SHOULD COMPLETE THE FOLLOWING:

• Adult Audiology Case History (PDF)
• Child Audiology Case History (PDF) – Birth to 17 years

PATIENTS TO BE SEEN FOR TINNITUS SHOULD COMPLETE THE FOLLOWING:

• Adult Audiology Case History or Child Audiology Case History (PDF) – Birth to 17 years
• Tinnitus History Questionnaire (PDF)
• Tinnitus Handicap Inventory (PDF)
• Perceived Stress Scale (PDF) – for patients 18 years and over
• Hyperacusis Questionnaire (teen – adult)

PATIENTS TO BE SEEN FOR SOUND SENSITIVITY (HYPERACUSIS) SHOULD COMPLETE THE FOLLOWING:

• Adult Audiology Case History or Child Audiology Case History (PDF) – Birth to 17 years
• Hyperacusis Questionnaire (PDF) – (teen – adult)
• Pediatric Hyperacusis Questionnaire (PDF) – for parents of children 12 years and younger
• Perceived Stress Scale (PDF) – for patients 18 years and over

PATIENTS TO BE SEEN FOR MISOPHONIA SHOULD COMPLETE THE FOLLOWING:

• Adult Audiology Case History or Child Audiology Case History (PDF) – Birth to 17 years
• Misophonia Questionnaire (PDF)
• Misophonia Assessment Questionnaire (PDF) – for patient
• Misophonia Family Questionnaire (PDF) – for significant other/s
• Central Sensitization Inventory (PDF)
• Perceived Stress Scale (PDF) – for patients 18 years and over
• Pediatric Hyperacusis Questionnaire (PDF) – for parents of children 12 years and younger
• Hyperacusis Questionnaire (PDF) – (teen – adult)

SPEECH AND LANGUAGE CLIENT FORMS

(Complete as appropriate)

• Adult Speech-Language Case History (PDF)
• Child Speech-Language Case History (PDF) – Birth to 17 years
• Adult Accent or Dialect Modification Case History (PDF)