UNCG Speech and Hearing Center
Department of Communication Sciences & Disorders
ACCENT OR DIALECT MODIFICATION CASE HISTORY
I. General Information
Today’s Date: ____________________
Name: _________________________________________ Date of Birth: _______________Gender: __________
Address:_____________________________________________________________________________________
Preferred phone # to call: ______________________ Alternate #_____________________________________
How did you learn about the UNCG Speech & Hearing Center? ____________________________________
Are you a non-native speaker of English interested in working on improving your spoken American English
skills? ___________
Are you a native speaker of English who speaks with a dialect other than standard American English? ______
Do you have an affiliation with UNCG? ____ If so, check one: Professor___ Student____ Interlink Student_____
Education- Mark the highest grade attended: 1 2 3 4 5 7 8 9 10 11 12 College: 1 2 3 4
Education beyond college? ___________________________________________________
Current Occupation: __________________________Employer__________________________________________
Marital Status: ____Married ____Widowed ____Separated ____Divorced ___Single
If you are attending a community college or university, what is your field of study or vocational goals?
____________________________________________________________________________________________
____________________________________________________________________________________________
Do you currently have a job? ____ What is your area of work?_____________________________________
____________________________________________________________________________________________
Describe your general health. _________________________________________________________________
____________________________________________________________________________________________
Do you have any hearing problems? ___________________________________________________________
What interests, hobbies, athletic abilities, or talents do you have? __________________________________
____________________________________________________________________________________________
II. For Accent Modification Clients Only (Non-native speakers of American English)
What is your native country? _________________________________________________________________
What is your first language? ________________________________ What other languages do you speak?
___________________________________________________________________________________________
On a scale of 1 to 5, ( with 1 being “limited” and 5 being “proficient”), rate how well you speak American
English _____, understand spoken American English_____, read American English____, and write in American
English_____.
Where and when did you learn American English? _______________________________________________
How long have you lived in the United States? ___________________________________________________
Is there anyone else in your household? ____________________ What language(s) do you primarily speak at
home? _______________________________________________________________________________________
524 Highland Avenue, 300 Ferguson Building, Greensboro, NC 27412
Phone: 336-334-5939 ~ Fax: 336-334-4475
Revised 08/12
2
Did you experience any speech problems in your first language? ______ If so, please describe ____________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Do people have trouble understanding your accent? _____ Please describe: ____________________________
_______________________________________________________________________________________________
Is your accent negatively impacting your career advancement? _______________________________________
Do you limit your professional or social interactions because of your accent? ___________________________
Do you feel stressed in public speaking situations because of your accent? _____________________________
Check the areas of American English in which you have the most difficulty ___ speech sounds
______ grammar _______ idioms/expressions
What are the specific goals you would like to achieve while working on your accent of dialect? __________
______________________________________________________________________________________________
III. For Dialect Modification Clients Only (Native speakers of American English)
What regional or cultural dialect do you speak (e.g. Southern English, Appalachian English, African American
English)? _______________________________________________________________________________________
Do people frequently ask you to repeat yourself because of your dialect? _______________________________
Do you ever experience a negative reaction to your dialect? ___________________________________________
Do you believe that learning to speak Standard American English in certain settings could have a positive
impact on your personal or professional life? _______________________________________________________