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Northwestern UniversityCenter for Audiology, Speech, Language & Learning2315 N Campus Dr, Evanston, IL 60208(847) 491-3165Auditory Processing QuestionnaireName:Age:School:Grade:Date:Primary concern/reason for referral?MEDICAL HISTORYHistory of Hearing LossHistory of Ear InfectionsPrenatal/Perinatal ComplicationsLanguage DevelopmentMotor edHistory of ADHDNoYesDiagnosed by/ProfessionAge of DiagnosisMedication (please administer prior to testing)Family History of:ADHD (attention deficit disorder)APD (auditory processing disorder)LD (learning disability)ACADEMIC SKILLSPlease indicate if your child is receiving any of the following special services in school?SpeechLanguagePhysical TherapyMy child attendsReadingOtherMathRegular EducationOccupational TherapySpecial EducationList any additional private services/tutoring your child receivesDisplays weak vocabulary skillsDisplays weak reading skillsDisplays weak writing skillsDisplays weak spelling skillsDifficulty explaining story/ideaReverses (when writing or bers

LISTENING SKILLSCan attend to auditory stimuli for more than a few secondsShort attention spanEasily distracted by background noiseDifficulty hearing in background noiseDifficulty with sound discriminationDifficulty following brief auditory directionsDifficulty following lengthy/complex auditory directionsDisplays slow or delayed response to verbal stimuliFrequently misunderstands what is saidExhibits low tolerance for noiseRemembers final directions better than initialADDITIONAL SKILLSMusic skillsArt skillsGeneral behaviorSpatial perceptionCoordinationUnderstands humorGets along well with othersHandednessAdditional Information:Revised NoNoNoNoNoNoNoNoNo

Northwestern University Center for Audiology, Speech, Language and Learning (NUCASLL)GENERAL CONSENTI.GENERAL CONSENTS AND ACKNOWLEDGEMENTSA. CONSENT FOR DIAGNOSIS, CARE AND TREATMENTI give permission for NUCASLL to provide medical services such as diagnosis, treatment, and clinicalprocedure that may be deemed necessary on my behalf. I acknowledge that no guarantees have been madeto me about the results of my examination or treatment by any NUCASLL clinician.B. ACKNOWLEDGEMENT OF EDUCATIONAL AND RESEARCH MISSIONSNUCASLL is dedicated to promoting quality services to the community. This mission is accomplished byproviding clinical care, training future professionals, and participating in clinical and translational research. Iunderstand that my care will be provided in a teaching environment and that professionals in training will beinvolved in my care and treatment.C. RECORDINGI am aware that audio and video recordings are used routinely during diagnostic (testing and interviewing)and treatment sessions and that there may be observers present during these sessions at NorthwesternUniversity. I, on behalf of myself and/or my minor child authorize audio and video recordings for clinicaldiagnostic, treatment and educational purposes within and external to Northwestern University includinglocal and national conferences by Northwestern University faculty and I will make no monetary or otherclaims against the University for their use. I understand that this permission extends to any and all sessionsthat I (or my minor child, if applicable) have at the Center for Audiology, Speech, Language and Learning.II.HEALTH INFORMATIONI understand that NUCASLL records medical and other information related to my diagnosis, care, and treatmentin electronic, video, audio, and other forms. I certify that any information regarding my history or medicalcondition communicated to NUCASLL is true and complete to the best of my knowledge. I understand that mymedical information is confidential and will only be used by NUCASLL staff for proposes related to my medicalcare and will only be released to others with my consent. I give permission for NUCASLL to exchange medicalinformation with my insurance company and/or their designated agents, the insurance policy holder, and /orother providers of healthcare services for purposes of insurance certification for tests or proceduresrecommended by NUCASLL providers. I also give permission to NUCASLL to provide medical informationnecessary to provide continuity of care recommended by NUCASLL staff to non-NUCASLL providers of healthcareor related diagnostic or therapeutic services.III.FINANCIAL RESPONSIBILITYI agree that I am financially responsible to and agree to pay NUCASLL for all services provided to me. NUCASLLbills current rates based on NUCASLL Chargemaster, which is a list of charges for services and supplies anddiscounted rates that may apply to those services or supplies.1 Page

If I choose to have my health insurance cover my treatment, I authorize NUCASLL to bill any such insurer for allmedical services and products provided. My insurance company may provide that some amount of the bill willremain my personal responsibility, such as my deducible, co-payment, or charge not covered by my healthinsurance. NUCASLL will bill me for the amount that is my responsibility. I understand my insurer may denypayment for services that the insurer decides are not “medically necessary” or that are “experimental”. WhileNUCASLL will take reasonable steps to appeal these denials, I understand that I am responsible for paying forservices denied by my insurer, including those deemed medically unnecessary or experimental.If I choose to have my health insurance pay for my treatment, I give up my rights to receive payment from myhealth insurance and assign the rights to receive payment to NUCASLL. I agree to cooperate and provideinformation as needed by NUCASLL to establish my eligibility for my insurance benefits.IV.RECEIPT OF WRITTEN MATERIALSI acknowledge receipt of NUCASLL’s Notice of Privacy Practices.V.RESEARCHNUCASLL is housed within Northwestern University's Roxelyn and Richard Pepper Department ofCommunication Sciences and Disorders (CSD), which houses a strong research arm and helps support ourmission of delivery of high quality clinical care. As a patient at NUCASLL, you are granted the opportunity toparticipate in a variety of research studies. Unless I check the “I do not agree” circles below:I give permission for NUCASLL to share my contact information with NU CSD researchers so that I may beI do not agreecontacted about participating in research projects.I give permission for NU researchers to access my past and future clinical information housed inNUCASLL medical record systems for research purposes. The information will always beI do not agreeused in an anonymous manner.VI.MARKETING AND EDUCATIONUnless I check the “I do not agree” circle below, I agree that to receive newsletters, fundraising information, and news aboutupcoming events, specials and articles pertaining to services or products in the clinic.I do not agreeVII.SIGNATUREMy written or electronic signature indicates my agreement with and acknowledgment of the above.Signature of Patient, Parent if patient is under 18,or Legally Authorized RepresentativeRelationship of Legally Authorized Representative to Patient2 PageDate of Signature

DIRECTIONS TO NORTHWESTERN UNIVERSITYCENTER FOR AUDIOLOGY, SPEECH, LANGUAGE, AND LEARNING2315 N Campus Dr.Evanston, IL 60208Via I-294: Exit at Dempster Street east.Go East on Dempster to Chicago Ave in Evanston.Turn left (north) onto Chicago Avenue, which will merge with Sheridan Road.Continue north on Sheridan to Lincoln Street and turn right (east).Lincoln Street becomes Campus DriveVia I-94: Exit at Old Orchard east.Go east on Old Orchard to Crawford Avenue in Evanston.Turn left (north) onto Crawford Avenue.Right right (east) onto Central Street, continuing until Sheridan Road.Turn right (south) onto Sheridan.Go two blocks to Lincoln Street, turning left (east) onto Lincoln.Lincoln Street becomes Campus DriveVia Lake Shore Drive: Enter Lake Shore Drive hearing north.When the Drive ends at Hollywood, turn right (north) onto Sheridan Road.Continue on Sheridan north into Evanston.Sheridan becomes South Boulevard.Continue on South Blvd., turning right (north) onto Chicago Avenue.Go north on Chicago, which becomes Sheridan Road.Continue north on Sheridan, turning right (east) on Lincoln Street.Lincoln Street becomes Campus Drive.- ‐ - ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- - ‐- ‐- ‐- ‐- ‐- ‐- ‐- - ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- ‐- - ‐- ‐- ‐- ‐- ‐Parking Directions at 2315 Campus Drive1. Follow Lincoln St. east of Sheridan Road as it turns into Campus Drive.2. Enter the North Parking Garage (the Center is located in this building).3. Take a parking ticket from the kiosk at garage entrance. Bring this ticket into the Center with you.You will be able to validate your parking ticket at the end of your appointment to guarantee freeparking.4. Reserved client parking spots are present on Level 3, but feel free to park anywhere you wouldlike. Handicapped spots are also available.5. Take Elevator “B” with the “Clinic Elevator” sign to Level 1 to enter the Center. Elevator “B” is in thesouthwest corner of the garage.6. When leaving, insert your validated ticket into the machine and you will be able to exit withoutpayment.

Street Entrance:Clinic visitors who are walking or being dropped off by car can enter the street entrance marked2315 Campus Drive on the southwest side of the building. The Center’s entrance is stepsaway. Elevator access to the parking garage is also available from this streetentrance.Phone: 847-491-3165Email: [email protected]: edu/clinic2315 Campus Drive, Evanston, IL 60208LakeMichiganEnter NorthCampusParking GarageHereGarageEntrance2315Campus Dr.Henry CrownSports PavilionFrancesSearleBuilding

CENTER FOR AUDIOLOGY, SPEECH, LANGUAGE AND LEARNING (NUCASLL)NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDAND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.NU STUDENTSIf you are a student of Northwestern University, we will maintain your medial information inaccordance with the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. 1232 g(“FERPA”). FERPA contains a right of access, subject to certain limitations, and restrictions ondisclosure. Please refer to your Student Handbook and in the Office of the Registrar’s website ,http://www.registrar.northwestern.edu/ferpa/, for detailed information about NorthwesternUniversity’s FERPA policies. In addition to FERPA, we will also maintain your medical information inaccordance with applicable Illinois law, including but not limited to: the Illinois Speech-LanguagePathology and Audiology Practice Act and the rules promulgated thereunder, the Illinois Code of CivilProcedure, the Illinois Mental Health and Developmental Disabilities Code and the Illinois MentalHealth and Developmental Disabilities Confidentiality Act.PATIENTS (OTHER THAN NU STUDENTS)Northwestern University (“NU”) Department of Communication Sciences and Disorders is one of thehealth care components of NU. NU is a not-for-profit teaching and research institution. TheDepartment operates three clinics: (i) Audiology Clinic, (ii) Speech, Language and Learning Clinic and(iii) Voice, Speech and Language Service and Swallowing Center. All services provided at the clinics areoverseen and supervised by Northwestern University faculty who are licensed health careprofessionals. Students of NU participate in clinical care as part of their education and training. ThisNotice applies to the information practices of the Department and its staff, faculty and students.We are committed to protecting your medical information. We maintain records of services providedfor your care and treatment. This Notice describes how we may use and disclose your medicalinformation contained in the records. We are required by law to: Maintain the privacy of your medical information; Give you this Notice of our legal duties and privacy practices with respect to your medicalinformation; and Follow the terms of this Notice or the current notice in effect.This Notice is effective August 1st, 2014. This Notice will remain in effect until we amend or replace it.We reserve the right to amend or replace this Notice at any time, and to apply the terms of therevised notice to all medical information that we maintain. All such amendments or revised notices willbe in accordance with applicable law. You may obtain a copy of the current notice on our website,www.communication.northwestern.edu by contacting our Privacy Officer or Assistant PrivacyOfficer. Our Privacy Officer is the chairperson of the Roxelyn and Richard Pepper Department ofCommunication Sciences and Disorders, currently Sumitrajit Dhar ([email protected]; 847 4913066). Our Assistant Privacy Officer, Aaron Wilkins, [email protected]; 847-491-3165.

The following sections describe different ways that we may use and disclose your medical information.For each category of uses or disclosures, we explain what we mean and give some examples. Notevery use or disclosure is listed. However, every use of disclosure falls into one of these categories.Also, in some cases Illinois law may limit us from disclosing special types of medical information. Forexample, Illinois law generally requires that we get your permission before disclosing mental health,alcohol/drug use and abuse, and HIV/AIDS information.ABOUT THIS NOTICEThe Northwestern University Center for Audiology and Speech Language and Learning is committedto protecting your health information. This Notice of Privacy Practices (“Notice”) is providedpursuant to the Health Insurance Portability and Accountability Act of 1196(“HIPAA”) as revised inthe 2013 HIPAA Omnibus Rule. This Notice describes how we may use and disclose your protectedhealth information to carry out treatment, payment or audiological and speech language andlearning /health care operations and for other purposes that are permitted or required by law. ThisNotice also describes your rights and our duties with respect to your protected health information.“Protected health information” is information about you that may identify you and that relates toyour past, present or future physical or mental health/condition and related audiological and speechlanguage and learning/health care services. We must follow the privacy practices that are describedin this Notice while it is in effect. If you have any questions about this Notice, please contactour Assistant Privacy Officer, Aaron Wilkins, at (847) 491-3165 or [email protected] WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION Thefollowing categories describe the different ways that we may use and disclose your protected healthinformation. These examples are not meant to be exhaustive, but to illustrate the types of usesand disclosures that may be made.1. TreatmentWe may use and disclose your protected health information to provide, coordinate, or manage youraudiological and speech, language and learning treatment and any related services. We may alsodisclose your protected health information to other third party providers involved in your audiologicaland speech, language and learning /health care. For example, your protected health information maybe provided to a physician or other audiological and speech language and learning /health careprovider (e.g. a specialist or laboratory) to whom you have been referred to ensure that the physicianor other audiological and speech language and learning /health care provider has the necessaryinformation to diagnose or treat you.2. PaymentWe may use and disclose your protected health information so that the treatment and healthcare services you receive may be billed to you, your insurance company, a government program, orthird party payors. This may include certain activities that your health insurance plan may undertakebefore it approves or pays for the audiological and speech language and learning /health careservices we recommend for you, such as making a determination of eligibility or coverage forinsurance benefits, reviewing services provided to you for medical necessity, and undertakingutilization review activities. For example, we may provide your health plan with medical informationabout the audiological and speech language and learning /health care services that the NorthwesternUniversity Center for Audiology, Speech, Language and Learning rendered to you for reimbursementpurposes.

Audiological/Health Care OperationsWe may use and disclose your protected health information for audiological and speech languageand learning /health care operation purposes. These uses and disclosures are necessary to makesure that all of our patients receive quality care and for our operation and management purposes. Forexample, we may use your protected health information to review the quality of the treatment andservices you receive and to evaluate the performance of our team members in caring for you. We alsomay disclose information to audiologists, speech language pathologists physicians, nurses, technicians,medical students and other personnel for educational and learning purposes.3. Treatment CommunicationsWe may provide treatment communications concerning treatment alternatives or other healthrelated products or services. For communications for which we or a business associate may receivefinancial remuneration in exchange for making the communication, we must obtain writtenauthorization unless the communication is made face-to-face and/or involving promotional giftsof nominal value. If you do not wish to receive these communications please submit a writtenrequest to our Assistant Privacy Officer, Aaron Wilkins, Northwestern University Center for Audiology,Speech, Language and Learning, 2315 Campus Drive, Evanston, IL 60208.4. Fundraising ActivitiesWe may use or disclose your demographic information and dates of services provided to you,as necessary, in order to contact you for fundraising activities supported by NorthwesternUniversity Center for Audiology, Speech, Language and Learning. You have the right to opt out ofreceiving fundraising communications. If you do not want to receive these materials, please submita written request to our Assistant Privacy Officer, Aaron Wilkins, NUCASLL, 2315 Campus Drive,Evanston, IL 60208.5. Others Involved in Your HealthcareUnless you object, we may disclose to a member of your family, a relative, a close friend or any otherperson you identify, your protected health information that directly relates to that person’sinvolvement in your health care. If you are unable to agree or object to such a disclosure, we maydisclose such information as necessary if we determine that it is in your best interest based onour professional judgment. Also, for example, if you are brought into this office and are unableto communicate normally with your clinician for some reason, we may find it is in your bestinterest to give your hearing instrument and other supplies to the friend or relative who broughtyou in for treatment. We may also use and disclose protected health information to notify suchpersons of your location, general condition, or death. We also may coordinate with disaster reliefagencies to make this type of notification. We also may use professional judgment and our experiencewith common practice to make reasonable decisions about your best interests in allowing a personto act on your behalf to pick up your hearing instruments, supplies, records, or other things thatcontain protected health information about you.6. Required by LawWe may use or disclose your protected health information to the extent that the use or disclosureis required by law. The use or disclosure will be made in compliance with the law and will be limitedto the relevant requirements of the law. You will be notified, as required by law, of any such usesor disclosures.7. Public HealthWe may disclose your protected health information for public health activities and purposes to a publichealth authority that is permitted by law to collect or receive the information. The disclosure will bemade for the purpose of controlling disease, injury or disability. We may also

disclose your protected health information, if directed by the public health authority, to a foreigngovernment agency that is collaborating with the public health authority.8. Business AssociatesWe may disclose your protected health information to our business associates that performfunctions on our behalf or provide us with services if the information is necessary for such functionsor services. To protect your health information, however, we require the business associate toappropriately safeguard your information.9. Communicable DiseasesWe may disclose your protected health information, if authorized by law, to a person who mayhave been exposed to a communicable disease or may otherwise be at risk of contractingor spreading the disease or condition.10. Health OversightWe may disclose your protected health information to a health oversight agency for activitiesauthorized by law, such as audits, investigations, and inspections. Oversight agenciesseeking this information include government agencies that oversee the audiological and speech,language and learning /health care system, government benefit programs, other governmentregulatory programs and civil rights laws.11. Abuse or NeglectWe may disclose your protected health information to a public health authority that is authorizedby law to receive reports of abuse or neglect. In addition, we may disclose your protected healthinformation if we believe that you have been a victim of abuse, neglect or domestic violence to thegovernmental entity or agency authorized to receive such information. In this case, the disclosurewill be made consistent with the requirements of applicable federal and state laws.12. Food and Drug AdministrationWe may disclose your protected health information to a person or company required by the Foodand Drug Administration to report adverse events, product defects or problems, biologic productdeviations, track products to enable product recalls, to make repairs or replacements, or toconduct post marketing surveillance, as required by law.13. Legal ProceedingsWe may disclose your protected health information in the course of any judicial or administrativeproceeding, in response to an order of a court or administrative tribunal (to the extent suchdisclosure is expressly authorized), and in certain conditions in response to a subpoena,discovery request or other lawful process.14. Law EnforcementWe may disclose your protected health information, so long as applicable legal requirements aremet, for law enforcement purposes.15. Coroners, Funeral Directors, and Organ DonationWe may disclose your protected health information to a coroner or medical examiner foridentification purposes, determining cause of death or for the coroner or medical examinerto perform other duties authorized by law. We may also disclose your protected health informationto a funeral director, as authorized by law, in order to permit the funeral director to carryout its duties. We may disclose such information in reasonable anticipation of death. Protectedhealth information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

16. ResearchWe may disclose your protected health information to researchers when their research hasbeen approved by an institutional review board that has reviewed the research proposal andestablished protocols to ensure the privacy of your protected health information.17. Serious Threat to Health or SafetyConsistent with applicable federal and state laws, we may disclose your protected healthinformation to prevent or lessen a serious threat to your health and safety or to the health andsafety of another person or the public.18. Military Activity and National SecurityIf you are involved with military, national security or intelligence activities or if you are in lawenforcement custody, we may disclose your protected health information to authorized officialsso they may carry out their legal duties under the law.19. Workers’ CompensationWe may disclose your protected health information as authorized for workers’ compensationor other similar programs that provide benefits for a work-related illness.20. For Data Breach Notification PurposesWe may use or disclose your protected health information to provide legally required notices ofunauthorized access to or disclosure of your health information.21. Required Uses and DisclosuresUnder the law, we must make disclosures to you and when required by the Secretary of theU.S. Department of Health and Human Services to investigate or determine our compliance withthe requirements of Section 164.500 et. Seq.SPECIAL PROTECTIONS FOR HIV, ALCOHOL AND SUBSTANCE ABUSE, MENTAL HEALTH AND GENETICINFORMATIONCertain federal and state laws may require special privacy protections that restrict the useand disclosure of certain health information, including HIV-related information, alcohol andsubstance abuse information, mental health information, and genetic information. Some partsof this Notice may not apply to these types of information.USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOURWRITTEN AUTHORIZATIONThe following uses and disclosures will be made only with your written authorization:1. Uses and disclosures of protected health information for marketing purposes for which we ora business associate may receive remuneration; and2. Disclosures that constitute a sale of protected health information.Other uses and disclosures of your protected health information not described in this Notice will bemade only with your written authorization, unless otherwise permitted or required by law. Youmay revoke this authorization, at any time, in writing, except to the extent that NorthwesternUniversity Center for Audiology, Speech, Language and Learning have taken an action in relianceon the use or disclosure indicated in the authorization. Additionally, if a use or disclosure ofprotected health information described above in this Notice is prohibited or materially limited byother laws that apply to use, it is our intent to meet the requirements of the more stringent law.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATIONThe following is a statement of your rights with respect to your protected health information anda brief description of how you may exercise these rights.1. Right to be Notified if there is a Breach of Your Protected Health informationYou have the right to be notified upon a breach of any of your unsecured protectedhealth information.2. Right to Inspect and CopyYou may inspect and obtain a copy of your protected health information that is contained inyour medical and billing records and any other records that Northwestern UniversityAudiology and Speech, Language and Learning Clinics use for making decisions about you. Toinspect and copy your medical information, you must submit a written request to ourAssistant Privacy Officer, Aaron Wilkins, Northwestern University Speech, Language andLearning Clinic, 2315 Campus Drive, Evanston, IL 60208. If you request a copy of yourinformation, we may charge you a reasonable fee for the costs of copying, mailing or othercosts incurred by us in complying with you request. Under federal law, you may not inspect orcopy the following records: psychotherapy notes; information compiled in reasonableanticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protectedhealth information that is subject to law that prohibits access to protected healthinformation. Depending on the circumstances, we may deny your request to inspect and/orcopy your protected health information. A decision to deny access may be reviewable. Pleasecontact our Assistant Privacy Officer, Aaron Wilkins, at (847) 491-3165 [email protected] if you have questions about access to your medical record.3. Right to Request RestrictionsYou may ask us not to use or disclose any part of your protected health information forthe purposes of treatment, payment or healthcare operations. You may also request that anypart of your protected health information not be disclosed to family members or friendswho may be involved in your care or for notification purposes as described in this Notice.To request a restriction on who may have access to your protected health information, youmust submit a written request to our Assistant Privacy Officer, Aaron Wilkins, NUCASLL ,2315 Campus Drive, Evanston, IL 60208. Your request must state the specific restrictionrequested and to whom you want the restriction to apply. Northwestern UniversityAudiology and Speech, Language and Learning Clinics are not required to agree to a restrictionthat you may request, unless you are asking us to restrict the use and disclosure of yourprotected health information to a health plan for payment or audiological and speech,language and learning /health care operation purposes and such information you wish torestrict pertains solely to a audiological and speech, language and learning /health care itemor service for which you have paid us “out-of-pocket” in full. If we believe it is in your bestinterest to permit the use and disclosure of your protected health information, yourprotected health information will not be restricted. If we do agree to the requested restriction,we may not use or disclose your protected health information in violation of that restrictionunless it is needed to provide emergency trea

Northwestern University . Center for Audiology, Speech, Language & Learning . 2315 N Campus Dr, Evanston, IL