Get the free Aphasia Referral Form

This document is a referral form for individuals seeking entry into programs at the Aphasia Institute – Pat Arato Aphasia Centre. It includes consent for sharing personal and health information, eligibility criteria for admission, and sections for medical history and communication ability assessments. The form outlines various programs available for those affected by aphasia, including the Introductory Program and Community Aphasia Program, and provides guidance on the referral process.

How to fill out aphasia referral form

How to fill out aphasia referral form

1. Obtain the aphasia referral form from the appropriate healthcare provider or institution.
2. Fill out the patient's personal information, including name, date of birth, and contact details.
3. Provide information about the patient's medical history and any previous diagnoses related to speech and language.
4. Describe the specific communication difficulties the patient is experiencing.
5. Indicate any relevant neurological or psychological assessments that have been conducted.
6. Complete the referral section with the details of the healthcare professional responsible for the referral.
7. Review all the provided information for accuracy and completeness.
8. Submit the form according to the guidelines provided by the referral institution.

Who needs aphasia referral form?

1. Individuals who have been diagnosed with aphasia or exhibit symptoms of communication difficulties.
2. Patients recovering from stroke or traumatic brain injury that impacts their ability to speak or understand language.
3. People with neurodegenerative conditions that affect speech and language, such as Alzheimer's disease or progressive aphasia.
4. Healthcare professionals who need to refer patients for specialized speech and language assessment and therapy.

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What is aphasia referral form?

The aphasia referral form is a document used by healthcare professionals to refer patients who may have aphasia for further evaluation and treatment.

Who is required to file aphasia referral form?

Healthcare providers such as doctors, speech-language pathologists, and other licensed professionals who identify potential cases of aphasia are required to file the aphasia referral form.

How to fill out aphasia referral form?

The aphasia referral form should be filled out by providing the patient's personal information, medical history, clinical observations, and any necessary test results, along with the referring provider's details.

What is the purpose of aphasia referral form?

The purpose of the aphasia referral form is to initiate the referral process for individuals suspected of having aphasia, ensuring they receive appropriate assessment and therapy.

What information must be reported on aphasia referral form?

The information that must be reported includes the patient's demographic information, symptoms, medical history, results of any previous assessments, and the reason for the referral.