Instructions

We look forward to working with you. If you are unable to come to our office for the evaluation, we can work with the candidate at a distance. Long-distance care is available through our In-Home Program which is individualized based upon a review of all of the following: (1) the applicant’s evaluation form; (2) telephone evaluation(s); and (3) a local audiologist’s report.

  • When you are ready to proceed with the evaluation, please fill in the following form.
  • To schedule the evaluation, call 828-683-6900 or email: info@aithelps.com. You can also go to our web site and submit a form request for an appointment. Do not hesitate to contact us with your questions.
  • When the evaluation is scheduled we will be glad to assess whether scholarship and/or payment plans are available to you. If you want us to do the additional financial assessment, please complete and submit the form entitled Scholarship, Payment Plans.
  • If the evaluation will be conducted at a distance, please schedule an appointment with a local audiologist for a hearing evaluation. We will send you a letter with instructions for the audiologist. Please instruct the audiologist to fax the results to us as soon as possible. If you have a child with special needs, we recommend that you find an audiologist who is trained to work with special needs children.

If AIT is appropriate, we can usually accommodate the In-Home Program fairly quickly. You will need a CD player; we supply the rest of the equipment. The AIT is 20 sessions, 1/2 hour each. The recommended program sequence is twice per day for 10 days. Re-assessments are included.

Do not hesitate to call us for further information or assistance: 828-683-6900.

AIT PRE-SCREENING EVALUATION FORM – NEEDS ASSESSMENT

* - required fields, please

MaleFemale

Physical/Medical Issues

YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

Developmental History:

YesNo
YesNo
Developmental milestones:
normal Limitsdelayed
normal Limitsdelayed
normal Limitsdelayed

Speech/Language and Hearing Issues

(identify if current or in past):

YesNo
YesNo
YesNo
(i.e., hearing sounds others do not hear or before others hear them)?
YesNo
YesNo
Easily UnderstoodDifficult for most people to understand
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

Psychological/Emotional or Neurological Issues

(identify if current or in past):

YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

Social Issues

YesNo

YesNo

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Note: This form is strictly confidential. The completion of this form in no way obligates you or the practitionerto perform AIT. It is only to help us determine what is in the best interest of the applicant.