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EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
1
Dear Prospective Client,
Thank you for contacting and interest in receiving services at the Edward D. Mysak Clinic for
Communication Disorders (EDMCCD). The EDMCCD is an integral part of the graduate training program
in speech and language pathology at Teachers College. The Clinic offers a wide range of diagnostic and
therapeutic services to individuals of all ages with communication disorders. These services are provided
by advanced graduate student clinicians who are enrolled in the Speech and Language Program at the
College. Graduate student clinicians provide these services under the direct supervision of the Clinical
Faculty. All of our Clinical Faculty are certified through the American Speech Language and Hearing
Association and hold New York State Licensure.
If you are interested in scheduling an evaluation or inquiring about beginning therapeutic services,
please fill out the intake forms included in this document. Once completed, the forms can be scanned
and returned via fax at 212-678-3409 or via regular mail to the address indicated below. Please do not
email the forms back. If you have records of any previous evaluations, please include the reports with
the intake forms.
We are looking forward to hearing from you.
Thank you,
The Mysak Clinic
(212) 678-3409
Edward D Mysak Clinic for Communication Disorders
Teachers College, Columbia University
Box 191
525 West 120th Street
New York, NY 10027
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
2
PEDIATRIC INTAKE FORM
Date Form Completed: ________________
Client’s Name: ____________________________ ���Male ���Female
Date of Birth: _____________ Age: _______ Parents/ Caregivers: _______________________
Parents are: ���Married/Partnership ���Separated ���Divorced
How many siblings? __________ Ages: _____________
Parent 1:
Address: ______________________________________________________________________
Preferred Phone: _____________ Home: ________________ Cell: ________________________
E-mail Address: ________________________________________________________________
Parent 2:
Address: ______________________________________________________________________
Preferred Phone: _____________ Home: ________________ Cell: ________________________
E-mail Address: ________________________________________________________________
Person filling out this form: ___________________Relationship to child: __________________
Referred by: ___________________________________________________________________
Has the child had a prior speech/language evaluation? ���Yes ���No
If yes, where & when? ___________________________________________________________
Has the child received any previous speech/language therapy? ���Yes ���No
If yes, where & when? __________________________________________________________
Has the child ever been evaluated by any other specialist? ���Yes ���No
If yes, please note the type of specialist(s), date(s) and reason(s): _________________________
*If the child has received any other evaluations please submit a copy of the
reports with this form.
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
3
History:
Is there a family history of:
Speech/language concerns? ���Yes ���No Family member: ______________________
Learning disabilities? ���Yes ���No Family member: ______________________
Reading problems? ���Yes ���No Family member: ______________________
Language best spoken & understood: ______________________________________________
Other languages spoken & understood: _____________________________________________
What are the primary concerns regarding this child’s speech and/or language?
______________________________________________________________________________
When was the problem first noticed? ______________________ By whom? ________________
Is the child aware of the problem? ���Yes ���No
How does the child react? ________________________________________________________
Over the last 6 months, has the problem: ���improved ���worsened ���remained the same?
Does the child prefer to: ���talk ���gesture
Does the child most frequently use: ���sounds ���words ���sentences
Does the child make sounds incorrectly? ���Yes ���No
If yes, please explain: ___________________________________________________________
Is the child’s voice different from other children of the same age? ���Yes ���No
If yes, please explain: ___________________________________________________________
Does the child stutter on words/sounds? ���Yes ���No
Does the child: Tell a simple story ���Yes ���No
Express thoughts & ideas ���Yes ���No
Understand what is said ���Yes ���No
Follow directions ���Yes ���No
Get along with other children ���Yes ���No
Prefer to play alone ���Yes ���No
Like to read ���Yes ���No
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
4
Listen to stories ���Yes ���No
What games/toys does the child enjoy? _____________________________________________
What television programs does the child enjoy? ______________________________________
Does the child attend: ���daycare ���preschool ���grade school (if so, what grade ___)
Is the teacher concerned? ���Yes ���No
Birth and Delivery Information:
This child is: ���biological ���adopted ���foster
Were there medical problems during the pregnancy? ���Yes ���No
If yes, please describe: ___________________________________________________________
List any medications taken during the pregnancy or the delivery: _________________________
_____________________________________________________________________________
Was the child born at full term? ���� Yes ���� No If no, how many weeks’ gestation? _______
Were there complications during delivery? ���Yes ���No
After delivery? ���Yes ���No
If yes, please describe: _____________________________________________________
Were there: Feeding problems? ���Yes ���No
Low birth weight? ���Yes ���No
Problems gaining weight? ���Yes ���No
Development:
Please list the ages that the child first met these developmental milestones:
Siting _____ Crawling_____ Walking____
Babbling_____ First Word ________ Sentences_____ Toilet Training_____
Did the child stop talking for a period of time? ���Yes ���No
If yes, when: ______________
Does the child have trouble hearing? ���Yes ���No
Has the child ever had a hearing test? ���Yes ���No
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
5
If yes, where and when? ______________________________________________________
Has the child had “tubes” in his/her ears? ���Yes ���No
Are the “tubes” still in? ���Yes ���No
Which hand does the child use most frequently? ���Left ���Right
Would you describe the child as coordinated? ���Yes ���No
List all current medications:
______________________________________________________________________________
______________________________________________________________________________
Medical history (please check all that apply):
Adenoidectomy ���Yes ���No
Allergies ���Yes ���No
Asthma ���Yes ���No
Bed wetting ���Yes ���No
Chickenpox ���Yes ���No
Chronic colds ���Yes ���No
Convulsions/seizures ���Yes ���No
Dental problems ���Yes ���No
Difficult to manage ���Yes ���No
Diphtheria ���Yes ���No
Drooling ���Yes ���No
Ear infections ���Yes ���No
Encephalitis ���Yes ���No
Headaches ���Yes ���No
Head injury ���Yes ���No
Heart problems ���Yes ���No
High fevers ���Yes ���No
Meningitis ���Yes ���No
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
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Mumps ���Yes ���No
Nasal regurgitation ���Yes ���No
Pneumonia ���Yes ���No
Rheumatic fever ���Yes ���No
Rubella ���Yes ���No
Scarlet fever ���Yes ���No
Snoring ���Yes ���No
Tonsillitis/tonsillectomy ���Yes ���No
Vision problems ���Yes ���No
Please describe any other health issues (accidents injuries, operations):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
7
MEDICAL RELEASE FORM
(This form is to be filled out by your doctor)
Your patient has requested the service of a speech language pathologist and/or audiologist.
The patient will be receiving these services at the Edward D. Mysak Clinic for Communication
Disorders at Teachers College, Columbia University. We appreciate your informing us about
your patient’s general health and immunization status. Thank you.
Patient’s Name: __________________________________ Date: __________________
Are immunization up to date? ���Yes ���No
Please describe any medical conditions that may affect the patient’s ability to participate in a
speech, language, and hearing evaluation or therapy?
Is there a history of seizures or other sudden changes in consciousness that we should be
aware?
Is the patient taking any medications regularly? If so, what for and are there side effects we
should be aware of?
Please describe any pertinent medical conditions or findings:
M.D. _____________________________________________
Address: __________________________________________
Phone: __________________________________________
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
8
Fee Policy
Fees are payable to Edward D. Mysak Clinic for Communication Disorders by using our online CashNet
system. Payments are not accepted at the clinic. Directions for paying your bill online will be provided
with your first statement. We do not accept insurance; however, after payment is made, we will be
happy to provide you with copies of documentation for you to submit to your insurance carrier.
��� Fees for all therapeutic services are charged by the semester, not by the session. Fees are not
refunded for absences. Please refer to the attendance policy for more detail.
��� Fees for all therapeutic services will be billed at the start of each semester. Fees are due by midsemester.
Clients who have not paid their bill in full by the end of the semester will not be
scheduled for further therapeutic sessions.
��� The Edward D. Mysak Clinical Staff will prepare specialized reports upon request. A consultation
fee of $100.00 will be billed for requests that require preparation beyond the duplication of file
documents.
��� A sliding fee scale is available for clients with a documented need. Please contact the Mysak
Clinic for an application.
��� The fee policy is subject to modifications each semester.
I have read the above fee policy and agree to comply with the terms and conditions of the policy.
_______________________________________
Name
_________________________________________ _________________________
Signature Date
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
9
BILLING FORM
Date: Semester:
Client: Date of Birth:
Name of person responsible for payments:
Relationship to client:
Address:

Home Phone:
Work Phone:
Cell Phone:
Email Address:
Person who will be bringing client to therapy:
___________________________________________________________________________________
FOR OFFICE USE ONLY – TO BE COMPLETED BY STUDENT
Treatment CPT – 92507 (Individual); 92508 (Group)
____ Articulation ____ Language ____ Fluency ____ Voice ____ Accent reduction
Treatment CPT-92609 (AAC)
____ Augmentative Communication
ICD-10 Code: __________________________________
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
10
CONFIDENTIALITY INFORMATION AND CONSENT FORM
I understand that as part of my health care, the Edward D. Mysak Clinic for Communication
Disorders (EDMCCD) at Teachers College, Columbia University maintains records about my
health as related to my speech, language, hearing and/or swallowing abilities. These records
describe my health history, symptoms, examination and test results, diagnoses, and any plans
for care or treatment. I understand that this information serves as:
��� a basis for planning my care and treatment;
��� a means of communication among the health professionals at the EDMCCD who
contribute to my care;
��� a source of information for applying my diagnosis and medical treatment
information to my bill;
��� a means by which a third party payer (i.e. insurance company) can verify that
services billed were actually provided should I decide to submit a claim to my
insurance company;
��� and a tool for routine health care operations within the EDMCCD, such as assessing
quality and reviewing the competence of health care professionals.
The attached Notice of Privacy Practices gives a more complete description of how my health
information may be used or disclosed by the EDMCCD at Teachers College. The Notice of
Privacy Practices also explains my rights regarding my personal health information, including
the right to access my own records and the right to request restrictions as to how my health
information is used or disclosed.
I understand it is my responsibility to notify the EDMCCD of any restrictions to the disclosure of
my health information regarding this or any subsequent visit.
I have been provided a Notice of Privacy Practices and have been given the
opportunity to review this information. I acknowledge this by my signature below.

____________________________________
Printed Patient’s Name Date

____________________________________
Signature of Patient or Legal Representative Date
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
11
NOTICE OF PRIVACY PRACTICES
The ECMCCD is not a covered entity under the Health Insurance Portability and
Accountability Act (HIPAA) and is not required by law to follow the requirements
of the HIPAA. However, we are committed to protecting the privacy of our client s
information and have created specific Confidentiality Policies that must be
upheld by all clinic staff and graduate clinicians. This notice describes how
medical information about you may be used and disclosed and how you can get
access to this information. Please review it carefully.
How we may use and disclose health information about you:
The Edward D. Mysak Clinic for Communication Disorders (EDMCCD) is committed to protecting
the privacy of all health information we create and maintain as a result of the health care we
provide you. Your “protected health information” (PHI) includes information about your past,
present, or future health, health care we provide you and payment for services that we provide
to you. The purpose of this notice is to explain who, what, when, where, and why your PHI may
be disclosed and assist you in making informed decisions when authorizing anyone to use or
disclose your PHI. We may use and disclose your PHI for the following purposes:
Treatment
We may use and disclose your PHI to provide you with clinical treatment and services. We may
disclose PHI to graduate clinicians, certified SpeechHLanguage Pathology supervisors, academic
faculty, or other personnel in the EDMCCD who are involved in taking care of you.
Payment
We may use and disclose PHI so that we may bill for treatment and services you receive at the
EDMCCD and can collect payment from you. The EDMCCD does not accept insurance and does
not directly bill third party payers.
Health Care Operations
We may use and disclose PHI for health care operations purposes. These uses and disclosures
are necessary to make sure that all of our clients receive quality care and for our operation and
management purposes. For example, we may use PHI to review the treatment and services you
receive and/or to check on the performance of our staff in caring for you. We also may disclose
PHI to students and/or faculty in the Communication Sciences and Disorders Program for
educational and learning purposes.
Appointment Reminders/Treatment Alternatives/Health Related Benefits and Services
We may use and disclose PHI to contact you to remind you that you have an appointment for
evaluation or treatment. We may also contact you to tell you about possible treatment
alternatives or health related benefits and services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
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We may disclose PHI to family or others identified by you or who are involved in your care or
payment of your care.
Legally Required Disclosures and Public Health
We may disclose PHI as required by law, including to government officials to prevent or control
disease; to report child, adult or spouse abuse; or to report reactions or problems with
products used in the EDMCCD.
Health Oversight Activities
We may disclose PHI to a health oversight agency for activities authorized by law. These
oversight activities include but are not limited to audits, investigations, inspections, academic
accreditation, and licensure. These activities are necessary for the government to monitor the
health care system, government programs, and compliance with civil rights laws.
Workers Compensation
We may disclose PHI for worker s compensation or similar programs.
Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a court or
administrative order. We also may disclose PHI in response to a subpoena, discovery request,
or other lawful process by someone else involved in the dispute, but only if efforts have been
made to tell you about the request or to obtain an order protecting the information requested.
Your Rights Regarding Health Information About You
You have the following rights, subject to certain limitations, regarding the PHI we maintain and
disclose:
Right to Inspect and Copy
You have the right to inspect and copy PHI that may be used to make decisions about your care
or payment for your care. We may charge you a fee for the costs of copying, mailing or other
supplies associated with your request.
Right to Request Amendments
If you feel that the PHI we have is incorrect or incomplete, you may ask us to amend the
information; however, you must disclose to us the reason for your request. A request for
amendments must be submitted, in writing, to the EDMCCD at the address listed at the
beginning of this document.
Right to an Accounting of Disclosures
You have the right to request an “accounting of disclosures” of PHI. This is a list of certain
disclosures we have made of PHI. The first list you request within a 12-month period will be
free. For additional lists, we may charge you for the costs of providing the list.
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
13
Right to Request Restrictions
You have the right to request a restriction or limitation on the PHI we use or disclose for
treatment, payment, or health care operations. You also have the right to request a limit on the
PHI we disclose about you to someone who is involved in your care or the payment for your
care, like a family member or friend. We are not required to agree to your request. If we agree,
we will comply with your request unless we terminate our agreement or the information is
needed to provide you with emergency treatment. All restriction requests must be submitted,
in writing, to the EDMCCD at the address listed at the beginning of this document.
Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain
way or at a certain location. For example, you can ask that we only contact you by email or only
by phone. Your request must specify how or where you wish to be contacted and must be
submitted, in writing, to the EDMCCD at the address listed at the beginning of this document.
We will accommodate reasonable requests.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice
electronically. You may request a copy of this Notice at any time by contacting the EDMCCD at
the address or phone number at the beginning of this document.
How to Exercise Your Rights
To exercise your rights described in this Notice, send your request, in writing, to Mr. Felix A
Matias, the EDMCCD Privacy Officer, at the address listed at the beginning of this document.
Changes to This Notice
We reserve the right to change this Notice. We reserve the right to make the revised or
changed Notice effective for PHI we already have as well as any information we receive in the
future The end of our Notice will contain the Notice s effective date.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with the
EDMCCD. To file a complaint with the EDMCCD, contact to Dr. Kathleen M. Youse, the EDMCCD
Privacy Officer, at the address listed at the beginning of this document. You will not be
penalized for filing a complaint.
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
14
For Mysak Clinic Use Only
Complete this section if this form is not signed and dated by the patient or patient’s
representative.
I have made a good faith effort to obtain a written acknowledgement of receipt of
the
EDMCCD Notice of Privacy Practices but was unable to for the following reason:
���Patient refused to sign
���Patient unable to sign
���Other __________________

_______________________________________ _________________________
Graduate Clinician’s Signature Date
Graduate Clinician’s Print name
_________________________________________ _________________________
Clinical Instructor’s Signature Date
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
15
E-MAIL CONSENT
1. RISK OF USING E-MAIL
The Edward D. Mysak Clinic for Communication Disorders (EDMCCD) offers clients the
opportunity to communicate by e-mail. Transmitting client information by e-mail, however, has
a number of risks that clients should consider before using e-mail. These include, but are not
limited to, the following risks:
��� E-mail can be circulated, forwarded, and stored in numerous paper and electronic files.
��� E-mail can be immediately broadcast worldwide and be received by many intended and
unintended recipients.
��� E-mail senders can easily misaddress an e-mail.
��� E-mail is easier to falsify than handwritten or signed documents.
��� Backup copies of e-mail may exist even after the sender or the recipient has deleted his
or her copy.
��� Employers and on-line services have a right to archive and inspect e-mails.
��� E-mail can be intercepted, altered, forwarded, or used without authorization or
detection.
��� E-mail can be used to introduce viruses into computer systems.
��� E-mail can be used as evidence in court.
2. CONDITIONS FOR THE USE OF E-MAIL
The EDMCCD will use reasonable means to protect the security and confidentiality of e-mail
information sent and received. However, because of the Risks outlined above, the EDMCCD
cannot guarantee the security and confidentiality of e-mail communication, and will not be
liable for improper use and/or disclosure of confidential information (including Protected
Health Information that is the subject of the federal Health Insurance Portability and
Accountability Act of 1996) that is not caused by the EDMCCD’s intentional misconduct. Thus,
clients must consent to the use of e-mail for client information. Consent to the use of e-mail
includes agreement with the following Conditions:
��� All e-mails to or from the client concerning diagnosis or treatment will be printed out
and made part of the client’s record. Because they are a part of the client’s record,
other individuals authorized to access the record, such as staff and billing personnel, will
have access to those e-mails.
��� The EDMCCD may forward e-mails internally to the EDMCCD’s staff and agents as
necessary for diagnosis, treatment, reimbursement, and other handling. The EDMCCD
will not, however, forward e-mail to independent third parties without the client’s prior
written consent, except as required by law.
��� Although the EDMCCD will endeavor to read and respond promptly to an e-mail from
the client, the EDMCCD cannot guarantee that any particular e-mail will be read and
responded to within any particular period of time. Thus, the client shall not use e-mail
for emergencies or other time-sensitive matters, including cancellations and schedule
changes within 48 hours.
��� If the client’s e-mail requires or invites a response from the EDMCCD, and the client has
not received a response within a reasonable time period, it is the client’s responsibility
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
16
to follow up to determine whether the intended recipient received the e-mail and when
the recipient will respond.
��� The client is responsible for informing the EDMCCD of any type of information the client
does not want to be sent by e-mail.
��� The client is responsible for protecting his/her password or other means of access to email.
The EDMCCD is not liable for breaches of confidentiality caused by the client or
any third party.
��� The EDMCCD shall not engage in e-mail communication that is unlawful.
��� It is the client’s responsibility to follow up and/or schedule an appointment if
warranted.
3. INSTRUCTIONS
To communicate by e-mail, the client shall:
a. Limit or avoid use of his/her employer’s computer or other public computers.
b. Inform the EDMCCD of changes in his/her e-mail address.
c. Put the client’s initials in the body of the e-mail.
d. Include the category of the communication in the e-mail’s subject line, for
routing purposes (e.g., billing question).
e. Review the e-mail to make sure it is clear and that all relevant information is
provided before sending to the EDMCCD.
f. Inform the EDMCCD that the client received an e-mail from the EDMCCD.
g. Take precautions to preserve the confidentiality of e-mails, such as using screen
savers and safeguarding his/her computer password.
h. Withdraw consent only by e-mail or written communication to the EDMCCD.
i. Contact the EDMCCD via phone (212) 678-3409 with any unanswered questions
before communicating with the EDMCCD via e-mail.
4. CLIENT ACKNOWLEDGMENT AND AGREEMENT
The names and e-mail addresses listed remain in effect until termination of services at the
EDMCCD. In the event that changes are made; a new consent form must be
completed.
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
17
I acknowledge that I have read and fully understand the information the EDMCCD has
provided me regarding the Risks of using e-mail. I understand the Risks associated with the
communication of e-mail between the EDMCCD and me, and consent to the Conditions
outlined on the previous page. In addition, I agree to the Instructions outlined, as well as any
other Instructions that the EDMCCD may impose regarding e-mail
communications.
��� I give permission for the EDMCCD to communicate by email with the following individuals:
_____________________________ ___________________________
Name Email address
_____________________________ ___________________________
Name Email address
_____________________________ ___________________________
Name Email address
By signing this contract, I indicate that I have read this document and understand the
contents.
Signature Print Name
Date
*
��� My signature below indicates that I DO NOT give e-mail consent and information WILL
NOT be exchanged through e-mail.
Signature Print Name
Date
EDWARD D. MYSAK CLINIC FOR COMMUNICATION DISORDERS
TEACHERS COLLEGE, COLUMBIA UNIVERSITY
18
CLINIC RELEASE FORM
The Edward D. Mysak Clinic for Communication Disorders has two major objectives. The first is
to provide professional services in the areas of speech, language, and hearing and the second is
to train graduate clinicians in the Department of Speech Language Pathology and Audiology.
Services rendered are provided by graduate clinicians working under the supervision of licensed
and qualified clinical staff and faculty. As this is a center housed within and associated with an
academic institution, it is necessary that clients be willing to cooperate with educational and
research activities as indicated below. Clients are assured that such activities will in no way
interfere with the quality of the services provided.
��� Services rendered will be provided by graduate clinicians, working under the supervision
of licensed and qualified clinical staff and faculty.
��� Any and all contact with clients may be observed through one-way mirrors; these will be
recorded and videotaped for teaching purposes.
��� Data collected during any interaction with the client may be used for research purposes,
but identifying information will be kept confidential at all times.
If you have any questions, please inquire before signing this document.
**This document remains in effect until services are terminated. **
__________________________________
Client’s Name
_____________________________________ _____________________
Client’s Signature (legal guardian for those <18) Date
(Lastname, Firstname @redlands.edu)</p>
Dear Health Care Provider,
Thank you for referring your patient to the Doernbecher Healthy Lifestyles Clinic.
The program is designed for children from ages 2-18 with a BMI at the 99th
percentile or greater. Our multidisciplinary team—including a pediatrician,
pediatric dietician, pediatric-trained physical therapist and pediatric behavioral
health psychologist—offers each patient a personalized approach to managing
childhood obesity.
Please note, prior to being admitted to the program, the following enrollment
requirements must be completed to ensure the child is a suitable match:
1. An application detailing the child’s dietary and activity habits.
2. Attendance at an hour-long information session about our program.
3. A clinic visit in your office within the previous three months with a blood
pressure measurement, a fasting lipid profile, CBC, fasting complete
metabolic panel and hemoglobin A1C if older than age 9. These must be
received by our office before scheduling an appointment in our clinic.
In addition, you may find the following suggestions helpful in your ongoing work
with children and families managing weight concerns:
1. Refer to a pediatric dietician and ensure your patient is eating breakfast
daily.
2. Pick no more than two diet and activity goals to work on with your patients.
3. The Doernbecher Healthy Lifestyles Clinic website under the “For Healthcare
Providers” section also offers further ideas and links to resources.
We look forward to collaborating with you to help improve the lives of overweight
or obese children and their families. Please feel free to contact us at 503 346-0644
with your questions or concerns.
Sincerely,
Natasha Polensek, M.D., Director
Kim Guion, Ph.D., Clinical Psychologist
Kerry Michaelis, P.T., D.P.T., P.C.S., Physical Therapist
Jennifer Kim, R.D., C.S.P., L.D., Clinical Dietician

LANGUAGES, LITERATURES AND CULTURES
Dear student:
Thank you for your interest in studying French at Ryerson. In order to help you achieve your full
learning potential, we need you to complete this self-assessment of your language skills.
Depending on your previous knowledge of French—which may range from non-existent to fairly
extensive—we have a course to meet your needs.
Please find below a series of statements that describe most of the students who enroll in our
courses. On the left-hand side, you will find a description of the level of knowledge you have
already achieved, and on the right-hand side, the course or courses in which you are allowed to
enroll. For example, if you have never received any formal instruction French, you may enroll in
C/FRE101, etc. If you have completed Grade 9-11 core French, you may not enroll in C/FRE101.
Once you have found the uppermost statement that describes your current situation, and you have
found the course that is likely to correspond to your skill level, please register in the FRE or CFRE
course corresponding to your level of French as indicated. Then, print the page, sign and date the
Statement of Agreement and hand it to your instructor on your first day of class. This will be
kept for our department records. You will be re-tested orally once in class, and if you are not at
the appropriate level, you may be dropped from the course or moved to another level, depending
on availability of space.
Note that if you are not entirely truthful and honest, or if you are trying to mislead the Department
of Languages, Literatures and Cultures about your previous knowledge of French, you are
committing Academic Misconduct (see section 2.3.3 of Policy 60 for a description of
consequences).
Also, please note that courses from 101 to 501 must be taken consecutively (one per term) only
and in ascending order. Once a certain level is achieved and passed, no matter the final grade,
you may not take a course at a lower level.
Note for students in the B.A. in Language and Intercultural Relations
Students in the Bachelor’s Degree in Language and Intercultural Relations are required to take
the online French placement test.
Dr. Kinga Zawada
Department Chair
French Language Self-Assessment
Check the box that best describes your knowledge of French.
Print and fill out this form and submit it to your instructor on your first day of class.
Which statement describes you best? ��� You should enroll in the following:
I have received NO formal instruction in French C/FRE 101 Introductory French I
I have completed Grade 9 and/or 10 core French
I have complete Grades 9, 10 and 11 core French or
C/FRE 101
C/FRE 201 Introductory French II
I have completed C/FRE 201 FRE 302 French Food, Wine and Hospitality
and/or C/FRE 301 Intermediate French II
I have completed Grades 9 to12 core or extended
French with a B- or above or C/FRE 201
C/FRE 301 Intermediate French I and/or C/FRE
402 French Pronunciation and Conversation
I have completed C/FRE 301 C/FRE 401 Intermediate French II and/or C/FRE
402 French Pronunciation and Conversation
I have completed Kindergarten to grade 12 French
Immersion or C/FRE 401
C/FRE 501 Speaking and Writing French I
I have completed C/FRE 501 C/FRE 601 Speaking and Writing French II and/or
C/FRE 515 Introduction to Business French
I completed my schooling in a Francophone school
to grade 12 or beyond, or C/FRE 501
C/FRE 601 Speaking and Writing French II or
C/FRE 510/610 Effective Writing I or II, etc.
Consult the French Pathway for further help in
planning your advanced courses.
I have completed C/FRE 601 Consult French Pathway for further help in
planning your advanced courses.
None of the above statements describes my current
situation, or I have completed a combination of the
above (extracurricular acquisition of French;
Francophone family background; French exchange
of more than a month, haven’t practised French for
over 5 years, etc.)
Please take the online French Placement Test
(lien), and ATTACH the placement letter you will
receive from our assessors to the Statement of
Agreement for our records.
STATEMENT OF AGREEMENT
I, the undersigned, declare that I have read and applied the French Language Self-Assessment thoughtfully and
accurately, and that I am enrolled, or will be enrolling, in the course that best matches my current knowledge of
French. I understand that providing inaccurate information, or deliberately enrolling in a course for which I am
overqualified is an act of academic misconduct, pursuant to Policy 60.
Name: __________________________________________________________________
Ryerson Student Number (if applicable): _______________________________________
Signature: _______________________________________________________________
Date: ___________________________________________________________________

posted by Isaac Hobart at 4:00 PM