Adult case history

Tell the story of how conversation changed, and what a kinder month would hold. This is not a quote of unpublished session rates.

Adult client

Client name *Date of birthPerson completing this form (if not the client)Relationship

Onset and medical history

When communication changed, and how it beganMedical diagnosis (stroke, brain injury, Parkinson’s, dementia-related change, other)Hospital, rehabilitation, or recent admissionsPhysician / neurologistPhoneMedicationsHearing or vision that affects conversationChewing or swallowing history to share with the physician (R.O.S.E. does not currently offer swallowing therapy as a standalone service)

Daily life

Where the person lives, and who is nearbyWork, retirement, or daily rolesLanguages usedHow conversation looks on a typical dayIf an AAC system is already in use, name itPrior speech-language therapyWhat would make the next month kinderSignature *Date *

Drafts stay on this device only. Printing creates a PDF through your browser. Emailing opens your mail app with a text summary. These templates support care and documentation; they are not a substitute for legal review of privacy or consent language.

Every journey begins with hope.
Every bloom begins with R.O.S.E.

Every bloom begins with R.O.S.E.