Note: Please contact us to have the forms emailed you to you electronically using Hushmail, an encrypted email system (see below). If you choose to fill out the forms below, you can print them and fill them out by hand. Some forms are in a fillable pdf format – these forms need to be downloaded to your computer, closed, and then reopened in order to save the information. Please return any forms by email to scheduling@csdshc.uncg.edu, by fax (336-334-4475), or by mail to: 300 Ferguson Building, UNCG, Greensboro, NC 27402.
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 (please sign)
- Notice of Privacy Practices (for review)
- Client Intake Form (please sign)
- Authorization for Disclosure of Protected Health Information (please sign)
- Telepractice Consent (for review)
- Email Consent (for review)
- Communication Permissions (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 (Birth to 17 years)
- Tinnitus history questionnaire
- Tinnitus handicap inventory
- Perceived Stress Scale (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 (Birth to 17 years)
- Hyperacusis questionnaire (teen – adult)
- Pediatric Hyperacusis questionnaire (for parents of children 12 years and younger)
- Perceived Stress Scale (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 (Birth to 17 years)
- Misophonia Questionnaire
- Misophonia Assessment Questionnaire (for patient)
- Misophonia Family Questionnaire (for significant other/s)
- Central Sensitization Inventory
- Perceived Stress Scale (for patients 18 years and over)
- Pediatric Hyperacusis Questionnaire (for parents of children 12 years and younger)
- Hyperacusis Questionnaire (teen – adult)
Speech and Language Client Forms
(Complete as appropriate)