University of Michigan Aphasia Program Application

Transcription

1 University of Michigan Aphasia Program Application Table of Contents Admission Considerations and Admission Procedure 2 Personal Information and Caregiver Information 3 Marital Information, Illness/Accident Information, and Language Skills 4 5 Previous Medical/Other Treatment 6 Educational History and Employment History 7 Personal Needs 8 Personal Interests 9 Referral Source Information 10 Medical Information Form 11 PLEASE READ AND FILL THIS OUT THOROUGHLY It helps us determine if UMAP is the right fit for you or your loved one.

2 2 Admission Considerations The University of Michigan Aphasia Program (UMAP) at the University Center for Language and Literacy (UCLL) is open to adults 16 and older with all types of aphasia and all levels of impairment. Clients enrolled without a caregiver must be independent in mobility and self-care. UMAP stands out among aphasia treatment programs because we are innovative, intensive, individualized. We offer the highest level of treatment to each client and their care partners. If you have questions about the application process or if you would like to schedule a tour of UMAP, please contact us at (734) or UCLL@umich.edu. The information gathered in this application will help us determine if UMAP is a good fit for you and, if so, will help us tailor our approach to your therapy. Admission Procedure 1. Complete and return the enclosed application. All information will be considered confidential and is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Admission is contingent upon the receipt of your application. Have your physician complete and return the Medical Information Form. 2. When your application is received by UCLL, records of hospitalization and rehabilitation services will be requested from the information you provide in your application. If you have copies of these records, forward them with your application to expedite the admission process. 3. The Clinical Services Manager will review the submitted information and determine if UMAP would be the right environment for the potential client. 4. Invitations are extended to applicants who can benefit from the program. We will contact you with session information and will get your enrollment started. A deposit is required to hold your space. 5. We'll answer any remaining questions you may have. For instance, the business office at UCLL can answer your financial questions, while our clinicians can answer therapy questions. Note: Enrollment is provided on a first-come, first-served basis in response to the invitation. We offer sessions throughout the year, and some fill quickly. If there is a session that works best for your family, please contact us right away to reserve your place. Th e University of Michigan, as an equal opportunity/affirmative action employer, complies with all applicable federal and state laws regarding non-discrimination and affirmative action, including Title IX of the Education Amendments of 1972 and Section 504 of the Rehabilitation Act of The University of Michigan is committed to a policy of non-discrimination and equal opportunity for all persons regardless of race, sex*, color, religion, creed, national origin or ancestry, age, marital status, sexual orientation, disability, or Vietnam-era veteran status in employment, educational programs and activities, and admissions. Inquiries or complaints may be addressed to the University s Director of Affirmative Action and Title IX/Section 504 Coordinator, 4005 Wolverine Tower, Ann Arbor, Michigan , (734) ; TDD (734) For other University of Michigan information call: (734) *Includes discrimination based on gender identity and gender expression.

3 Personal Information 3 Name of Applicant Address City State ZIP Home Phone ( ) Work Phone ( ) Cell Phone ( ) Date of Birth Age Sex: Male Female Have you applied to this program before? Yes No If yes, when? Preferred months of attendance Name of person completing this form Name Caregiver Information Relationship to Applicant Home Phone ( ) Work Phone ( ) Cell Phone ( ) Will someone be accompanying the applicant to the session? Yes No If yes, who?

4 4 Marital Information Marital Status Spouse s/partner's Name Spouse s/partner's Occupation Home Phone ( ) Work Phone ( ) Cell Phone ( ) Spouse s/partner's Illness/Accident Information Nature of Illness/Accident Date Were you unconscious? Yes No If yes, for how long? Were you paralyzed? Yes No If yes, where? Were you right- or left-handed before the present problem? Language Skills It is helpful to understand as much as possible about your communication abilities prior to attending the program. Describe your language skills. Check all that apply: Speaks in single words phrases sentences Formulates questions Carries on conversations Comprehends single words yes/no questions wh-questions conversations Reads single words newspapers novels Writes name single words sentences

5 Previous Speech-Language Therapy 5 Name of Facility Dates Attended Frequency of Attendance Phone ( ) Report Available Acute Care Hospital Rehabilitation Hospital Outpatient/Home Care Name of Facility Dates Attended Frequency of Attendance Phone ( ) Report Available Acute Care Hospital Rehabilitation Hospital Outpatient/Home Care Name of Facility Dates Attended Frequency of Attendance Phone ( ) Report Available Acute Care Hospital Rehabilitation Hospital Outpatient/Home Care

6 6 Name of Facility Dates Attended Previous Medical/Other Treatment Name of Professional Frequency of Attendance Phone ( ) Report Available Occupational Therapy Physical Therapy Psychological Testing Vocational Testing Other Name of Facility Dates Attended Name of Professional Frequency of Attendance Phone ( ) Report Available Occupational Therapy Physical Therapy Psychological Testing Vocational Testing Other Name of Facility Dates Attended Name of Professional Frequency of Attendance Phone ( ) Report Available Occupational Therapy Physical Therapy Psychological Testing Vocational Testing Other

7 Educational History 7 Pleas indicate the highest level of education you have attained. Less than 12 years Partial high school Less than 8th grade High school graduate Some college College graduate Advanced degree (MBA, MA/MS, Ph.D., etc.) Which educational institution did you most recently graduate from? Is English your native language? Yes No If no, what is your native language? Please indicate the highest level of education attained by your spouse/partner. Less than 12 years Partial high school Less than 8th grade High school graduate Some college College graduate Advanced degree Employment History What was your most recent occupation? Who was your most recent employer? Where was the company located?

8 8 Personal Needs Are you on a special diet? Yes No If yes, please describe. Do you have any allergies? Yes No If yes, please describe. Can you take your medication independently? Yes No Would you like medication reminders? Yes No Do you use a hearing aid? Yes No If yes, please describe. Can you walk independently? Yes No If no, please describe. Do you use a wheelchair? Yes No If yes, please describe. Are you independent in going to the restroom? Yes No If no, please describe. Are you able to follow a schedule without direct supervision? Yes No Are you able to manage your time without direct supervision? Yes No

9 Personal Interests 9 We make sure each of our clients receives a tailored approach to therapy at UMAP. The following information will help us to customize your program. Describe 3 previous jobs. Describe 2-3 special hobbies. Describe 2-3 activities you enjoy doing. List 2-3 books you would like to read. List your family members and their ages.

10 10 Referral Source Information To help us better understand how our applicants find UMAP, please tell us how you heard about us. Professional (speech-language pathologist, physician, etc.) (please specify): Name Profession Hospital or Affiliation Work Phone ( ) Cell Phone ( ) Former UMAP Client or Family Member (please specify): Media (newspaper article, radio, etc.) An Advertisement (StrokeSmart Magazine, HOUR Detroit, etc.) Web Search (Google, Yahoo, Bing, etc.) UMAP Website ( UMAP enewsletter Social Media such as Facebook or Pinterest Print Material (brochure, magnet, etc.) Conference or Event Other (please specify):

11 Medical Information Form - Page 1 of 2 (To be completed by your physician) 11 The University of Michigan Aphasia Program (UMAP) offers intensive intervention programs for adults with speech and language difficulties due to brain injury. Each client receives 14 hours of individual therapy and 10 hours of group therapy weekly. In addition, the program may be supplemented with daily homework, music therapy and computer activities. Although the program is self-contained in one building, clients must move from session to session, use an elevator, and be able to care independently for their needs. Complete this form and fax it to us at (734) , it to us at ucll@umich.edu, or mail it to: University of Michigan Aphasia Program c/o Clinical Services 1111 E. Catherine St. Ann Arbor, MI Patient Name Date of Birth Date of Onset Etiology of Communication Impairment Medications Dosage Frequency Allergies Other Conditions (check all that apply): Hemiparesis Hypertension Heart Disease Syncope Ulcers Seizures Diabetes Chronic Headaches Visual Field Deficits Conditions other than those listed above:

12 12 Medical Information Form - Page 2 of 2 (To be completed by your physician) Dietary Restrictions Date of Last Completed Physical Exam Do you see this patient routinely? Yes No Do you feel your patient would be physically capable of participating in an intensive speech-language program as described? Yes No Would you recommend that your patient participate in this intensive speech-language program? Yes No Would your patient require any medical monitoring if involved in our program? Yes No If yes, please describe. Physician s Signature Physician s Name (print) Address City State ZIP Phone ( ) Date Physician s NPI# Thank you. A copy of the final report will be sent to you after appropriate release forms have been signed.