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Parkinson Voice Project Intake Form

This form is for Texas patients only.

This field is for validation purposes and should be left unchanged.

SPEAK OUT!® Therapy is best completed on a computer, laptop, or iPad. Mobile phones should not be used for therapy sessions.

I have access to a computer, laptop, or iPad for SPEAK OUT! Therapy(Required)
Expectations:(Required)
MM slash DD slash YYYY
Gender(Required)
Referred to clinic by (please check one box):(Required)
MM slash DD slash YYYY
Have you been hospitalized in the last year?(Required)
Relationship Status:(Required)
Patient Resides:(Required)
Employment Status:(Required)
Have you received speech or swallowing therapy in the past?(Required)
Was the therapy helpful?
Have you noticed changes in your swallowing?(Required)
Have you had a Modified Barium Swallow Study in the last year? (If yes, please send us a copy of the report.)(Required)
Have you ever had aspiration pneumonia?(Required)
Check all that apply:(Required)
May we discuss your health information with this person?(Required)
May we discuss your health information with this person?

To receive services from Parkinson Voice Project, please acknowledge the following:

Parkinson Voice Project does not bill Medicare, insurance, or patients for therapy services. We are a nonprofit organization funded primarily through donations.(Required)
Parkinson Voice Project staff cannot provide one-to-one mobility assistance. If I have impaired mobility, I must use an appropriate assistive device and/or have a care partner with me in the clinic to ensure my personal safety and to decrease the risk to others.(Required)
Parkinson Voice Project utilizes a HIPAA-compliant web-based platform to provide teletherapy services.(Required)
Please read the following statements. Check each box to express agreement.(Required)
I agree that the information provided is accurate and complete to the best of my knowledge.(Required)
MM slash DD slash YYYY