Adult Case History Form

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Client ID

Case ID

Client Details

First Name

Last Name

Mailing Street (including Apartment/Suite)

City

State/Province

Postal Code

Country

Mobile Phone

Client's Email

Native Language of Client

Date of Birth

Referred by:

Referred by Other:

Employer

Please describe your concerns and goals for speech therapy:

Page 3

Client Demographic Information

Gender

Pronouns

Race

Other Pronoun

Ethnicity

Consent & Electronic Signature

I give permission for the American Institute for Stuttering (AIS) to observe and videotape me under the supervision of my clinician, by treatment staff, and/or interns. The purpose of this observation is to advance the education and treatment of those who stutter

I agreeI do not agree

Statement and Certification:

I verify that all of the information I have provided is true and correct to the best of my knowledge.I adopt the electronic signature provided below by typing my name.I give permission for American Stuttering Institute to contact me regarding the services I've requested.

Client Electronic Signature

Date of Electronic Signature

Please enter today's date

Financial Assistance

I would like to apply for financial assistance through AIS to help pay for my treatments.

YesNo

WASSP Rating Sheet

Please rate each of the following aspects of your stutter using a 7-point scale, 1 indicating "None" and 7 indicating "Very Severe". Please select the number which you judge best describes each aspect of your stutter.

Stuttering Behaviors

	1 (None)	2	3	4	5	6	7 (Severe)
Helplessness
Frequency of Stutters
Physical struggle during stutters
Duration of stutters
Uncontrollable stutters
Urgency/fast speech rate
Associated facial/body movements
General level of physical tension
Loss of eye contact
Other (Describe)

Other Description

Avoidance due to stuttering

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	1 (None)	2	3	4	5	6	7 (Severe)
Negative thoughts before speaking
Negative thoughts during speaking
Negative thoughts after speaking

	1 (None)	2	3	4	5	6	7 (Severe)
Of words
Of situations
Of talking about stuttering with others
Of admitting your problems to yourself

	1 (None)	2	3	4	5	6	7 (Severe)
At home
Socially
Educationally
At work

	1 (None)	2	3	4	5	6	7 (Severe)
Frustration
Embarrassment
Fear
Anger
Helplessness
Other (Describe)