Adult Case History Form

| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

If you have an email invitation with your client ID and case ID, please fill in that information below


Client Details















Page 2

Health History





Speech & Language History















Page 3

Client Demographic Information





Consent & Electronic Signature




Please enter today's date
Financial Assistance

WASSP Rating Sheet

Please rate each of the following aspects of your stutter using a 7-point scale, 1 indicating "None" and 7 indicating "Very Severe". Please select the number which you judge best describes each aspect of your stutter. 
Stuttering Behaviors
1 (None) 2 3 4 5 6 7 (Severe)

Thoughts about stuttering
1 (None) 2 3 4 5 6 7 (Severe)
Feelings about stuttering
1 (None) 2 3 4 5 6 7 (Severe)

Avoidance due to stuttering
1 (None) 2 3 4 5 6 7 (Severe)
Disadvantage due to stuttering
1 (None) 2 3 4 5 6 7 (Severe)