UW—EAU CLAIRE
CENTER FOR COMMUNICATION DISORDERS
INTAKE & REQUEST FOR SERVICES
INTAKE DATE
STAFF MEMBER CONDUCTING INTAKE
CLIENT NAME
D.O.B
AGE
PARENT/CAREGIVER NAME
PHONE(S)
PREFERRED METHOD OF CONTACT
EMAIL
ADDRESS
REFERRED BY (IF APPLICABLE)
AREA(S) OF NEED FOR SPEECH/LANGUAGE
Speech-sound use/Phonology
Social skills
Voice
Other:
Language understanding
Reading/writing
Language use
Fluency
MEDICAL/OTHER ISSUES OR CONCERNS?
PREVIOUS SERVICES ELSEWHERE?
INDICATE BELOW AS DESIRED
We are interested in an evaluation at this time (evaluations are offered during the academic year only).
Please put this individual on the CCD waiting list for intervention services at this time.
We are interested in ONLY individual services
OR
We are interested in individual OR group services
Indicate Availability Below
M
T
W
Th
Mornings
Early Afternoon
(1:00-3:00)
Late Afternoon
(3:00-6:00)
Complete Form and Email (hagedoke@uwec.edu), Fax (715-836-4846) or
Mail To (UWEC, Center for Comm Disorders, Attn: Kay Hagedorn 239 Water St, EC 54701)
You will be contacted if an opening becomes available.
Center for Communication Disorders
TERMS OF SERVICE
The Center for Communication Disorders (CCD) is a regional resource for a full range of
diagnostic and therapeutic services for individuals with speech, language, and hearing
disorders.
Services are provided for all ages and all types of communication disorders.
All treatment and diagnostic services at the CCD are provided by undergraduate and graduate
student clinicians under the direct supervision of speech-language pathologists and
audiologists who hold certification from the American Speech-Language-Hearing Association
(ASHA) and licensing from Wisconsin’s Department of Regulation and Licensing (DRL).
The CCD is open in conjunction with the University’s calendar system (11 weeks each Fall and
Spring).
Due to the nature of the CCD as a training facility, we offer quality services at significantly
reduced rates. Information regarding fees is available upon request.
Clients are scheduled for services on the basis of the availability of clinicians and supervisors,
as well as the demands of the curriculum and need for particular clinical experiences. New
and/or continuing services cannot be guaranteed at any point.
The CCD complies with the UW—Eau Claire Statement of Affirmative Action/Equal Opportunity
and does not discriminate against persons regardless of race, color, creed, sex, age, religion,
marital status, sexual orientation, national origin, family design, or disability.
Questions? Contact Angie Sterling-Orth (Director of Clinical Programs & Services) at
sterliaj@uwec.edu or call 715-836-4186.