IPC Services Inquiry Form

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Services Inquiry Form

Thank you so much for your interest in participating in our services at the MGH Institute of Health Professions Sanders IMPACT Practice Center (MGH IHP IPC). We are excited that you want to join our health professions graduate students in our interprofessional learning and practice environment. We pride ourselves on being student and client-centered and grounded in principles of justice, equity, diversity, inclusion, and evidence-based practice.

We'd like to know more about the person interested in joining us and the types of services they are interested in participating in. This form may be completed by the individual seeking services and or a guardian/caregiver on their behalf. Thank you in advance for completing the form below!

Today's Date:

M-D-Y

Client's First and Last Name:

* must provide value

Client's date of birth (DOB)

* must provide value

M-D-Y

Person filling out this form (First and Last Name):

Person filling out this form's relationship to the client:

* must provide value

Person filling out this form's phone number:

Client's phone number (if different from above):

Person filling out this form's e-mail address:

Client's email address (if different from above):

Preferred Method of Contact (check all that apply):

Phone

City of Residence

* must provide value

State of Residence

* must provide value

Are you a current client of the IMPACT Practice Center?

* must provide value

Yes

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Which programs are you currently participating in at the IPC?

Audiology

Nursing

Occupational Therapy

Physical Therapy

Speech Language Pathology

Please describe the current primary concern(s):

* must provide value

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Audiology Services:

Hearing evaluation

Hearing aid services (currently using hearing aids)

Hearing aid services (not currently using hearing aids)

Other audiology services

Nursing Services:

Adult health screenings, chronic illness management, and health promotion/wellness education

Pediatric health screenings, chronic illness management, and health promotion/wellness education

Postpartum health screening and health promotion/wellness education for mother/guardian and child

Adult mental health (supportive counseling)

Pediatric mental health (supportive counseling)

Care partner support group

Occupational Therapy Services:

Adult occupational therapy

Pediatric occupational therapy

Physical Therapy Services:

Adult physical therapy

Pediatric physical therapy

Speech Language Pathology Services:

Acquired or degenerative disorders (e.g., aphasia, brain injury, Parkinson's)

Spaulding-Institute of Health Professions Comprehensive Aphasia Program (S-IHP's CAP)

Speech sound production

Expressive and/or receptive oral language

Written expression (sentence and paragraph-level writing)

Cognition (e.g., planning, organizing, problem-solving)

Augmentative and alternative communication (AAC)

Reading and spelling

Smartphone, tablet, and computer training

How did you hear about the IMPACT Practice Center?

* must provide value

Learned of services through Tedy's Team Center of Excellence in Stroke Recovery

MGH occupational therapist referred us

MGH physical therapist referred us

MGH speech-language pathologist referred us

School nurse referred us

School occupational therapist referred us

School physical therapist referred us

School psychologist referred us

School speech-language pathologist referred us

Spaulding Rehab occupational therapist referred us

Spaulding Rehab physical therapist referred us

Spaulding Rehab speech-language pathologist referred us

Teacher referred us

Other

If you selected 'other', please state how you learned of the Sanders IMPACT Practice Center.

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