Get Sgd Eval Intake Form.pdf - Kansas Speech-language-hearing ... - Ksha

Filling out the SGD Eval Intake Form is a critical step in the evaluation process for speech-language and hearing services. This guide will provide clear and detailed instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully fill out the form.

1. Click the ‘Get Form’ button to obtain the form and open it in the appropriate editor.
2. Begin by filling in the patient's information: name, date of birth, evaluation date, phone number, email, and fax number as requested in the top section of the form.
3. Next, indicate the name and relationship of the person accompanying the patient, along with the physician's name, UPIN number, and their contact details.
4. Provide insurance information, including primary and secondary insurance details, contact persons, and upload any necessary copied cards.
5. Fill in the patient's medical history, including speech-related problems, neurological issues, and any other pertinent health information.
6. Describe the patient's living situation, whether they have any pre-literate children in the family, and detail the communication environments they engage with on a daily basis.
7. Note any changes in social, professional, or community activities due to reduced speech or computer access, ensuring to capture specific examples.
8. Complete the cognitive characteristics section, indicating challenges with spelling, initiation, or disinhibition.
9. Provide details on speech characteristics, including intelligibility, voice quality, rate of speech, and any additional observations.
10. Fill in information related to dysphagia, hearing abilities, vision, and mobility challenges, as well as details about any equipment used.
11. Indicate the recommended system for communication, along with any trained speech-generating devices demonstrated and reasons for selecting or not selecting each.
12. Specify the access methods, access sites, and any additional equipment needed for communication.
13. Finally, complete the follow-up items and notes sections to ensure all relevant information is recorded. After filling in the necessary fields, you can save changes, download, print, or share the completed form.

Complete your documents online today for efficient processing.