SPEECH AND HEARING CENTER

DEPARTMENT OF COMMUNICATION SCIENCES AND DISORDERS

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 with instructions to create a secure passphrase to protect your private health information.  A passphrase is a series of words that is easy for you to remember, but hard to guess.  It is case sensitive and can include numbers and special characters, but not spaces (e.g., icheerforuncgspartans!).  Please write this passphrase down as you will need it for future email communications with the Center.  Check your spam if you do not receive the email as expected.

New Client Forms

All clients should complete the following:

Audiology Forms

Patients to be seen for evaluation of hearing or auditory processing should complete the following:

Patients to be seen for tinnitus should complete the following:

Patients to be seen for sound sensitivity (hyperacusis) should complete the following:

Patients to be seen for misophonia should complete the following:

Speech and Language Client Forms

(Complete as appropriate)