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:
- Client Information Form (please sign)
- Notice of Privacy Practices(for review)
- Acknowledgement of Receipt of Notice of Privacy Practices (PDF) (please sign)
- Authorization for Disclosure of Protected Health Information (please sign)
- Authorization for Observation and Training Form (please sign)
- Method of communication permission (PDF) (please sign)
- Electronic Communication Permissions (PDF) (please sign)
- Telepractice Consent (PDF) (for review)
- Email Consent (PDF) (for review)
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 (PDF)
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)
- 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)
Speech and Language Client Forms
(Complete as appropriate)