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Lingraphica Operations Requests
Internal Patient Benefit Check
Internal Caregiver Benefit Check
Internal Professional Benefit Check
Internal Patient Benefit Check
Internal Caregiver Benefit Check
Internal Professional Benefit Check
Internal Professional VA Intake
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Internal Professional VA Intake
Speech-Language Pathologist Information
Hidden
Sales Channel
*
SLP
Who is completing this intake?
*
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Abigail Ridgeway
Angela Mooney
Anna Reeve
Ariel Moniz
Beth McHose
Brian Zimmerman
Charly Essner
Chris Brady
Chris Mangin
Cristina Franco
Deanna Martin
Diane Martinez
Emily Carvill
Evy Tews
Felicia Bradley
Giuseppe Ceballos
Izzy Bareiss
Jennifer Hanson
Jennifer Toland
Jessica Gabaldon
Jessica Shaffer
Katherine Baine
Katherine Hamilton
Kelly Cantrell
Kelly Case
Kirstie Sabella
Laura Reichl
Maria Gallego
Melanie Guerrero
Michelle Phillippy
Myriam Villarreal
Paola Cevallos
Rachel Lyons
Reva Fuller
Ryan Lynch
Sara Schneider
Sarah Mead
Sherilyn Gutierrez
Stephanie Kurtz
Teresa Thompson
Whitney Cobas
William Shaffer
Have you previously conducted a Lingraphica device trial?
*
Yes
No
Name of Speech Therapist
*
First
Last
Email
*
Enter Email
Confirm Email
Do you use your mobile phone, work phone, or both?
*
Mobile Phone
Work Phone
Both
Mobile Phone Number
*
Work Phone Number
*
Extension
How would you like us to contact you?
*
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Call
E-mail
Text (Mobile only)
By selecting "Text," you agree to receive SMS messages from Lingraphica. If you do not wish to receive SMS messages from Lingraphica, please choose a different contact method.
Have you participated in any of the following with Lingraphica? (Check all that apply)
*
Online CEU Course
Live Webinar
On-Site Patient Consultation
On-Site In-Service
Lingraphica Certification Program
None
Who conducted the in-service, webinar or on-site visit?
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Amanda D'Augustino
Amanda Gunn
Amanda Santarlas
Amelia Bergmann
Amy Bowman
Amy Preci
Angela Gamarra-Rivera
Anna Reeve
Ariel Moniz
Ashley Bradley
Audi Cathcart
Bailey Shafer
Beth McHose
Bonnie McNutt
Brianne Kosch
Brittany Karp
Caitlin Mueller
Catherine Sweet
Chelsea Zimmerman
Christina Bravo James
Daria Ross
Elizabeth Robinson
Faye Stillman
Isabella Bareiss
Jacalyn Baxendale
Jennifer Ackett
Jennifer Barr
Jennifer DeFluiter
Jennifer Hanson
Jennifer Stanley
Julie Legters
Kate Diehl
Katherine Baine
Kaylen Giadrosich
Kelly Cantrell
Kelsey Akinsinde
Kerry Nulman
Laura Reichl
Lindsey Clark
Matthew Tisdale
Melissa Palao
Michelle Phillippy
Monica Morkos
Nikki Bolick
Renee Smith
Sara Porter
Sarah Mead
Sara Schneider
Shawnise Carter
Teresa Thompson
Tyler White
Vanessa Stocki
Victoria Stezzi
Whitney Cobas
I don't know
Are you interested in scheduling a virtual in-service with a Lingraphica representative?
*
Yes
No
Requested Trial Device Information
Which Lingraphica Communication Device would you like to trial?
*
All of Lingraphica's communication devices have the same software. The only difference is size/form factor. To learn more about our devices, visit
https://lingraphica.com/aac-devices/
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TouchTalk
TouchTalk Plus
MiniTalk
Which accessories would you like to trial? (Choose all that apply)
*
In addition to the standard case and stylus, please select up to 2 (two) accessories from the list below. Select None if you do not wish to trial any accessories. To learn more about accessories visit
https://lingraphica.com/aac-devices/aac-device-accessories
.
Standard Mouse (Wireless)
Joystick
Stylus Tether
Wireless Keyboard
EZ Eyes Keyboard
Ball Stylus
Extended Stylus
T Stylus
Weighted Stylus
Flexible Stylus with Strap
Long Flexible Stylus
Rugged Case (MiniTalk only)
None (all devices come with a standard case and stylus)
Shipping Information for Trial Device
Please note: Trial devices
must
be sent to the speech-language pathologist. A signature is required for delivery of the trial device.
Which VA Medical Center do you work for?
*
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00 - VA Medical Center Not Listed
AK - Colonel Mary Louise Rasmuson Campus of the Alaska VA Healthcare System
AL - Birmingham VA Health Care System - Birmingham VA Medical Center
AL - Central Alabama VA Medical Center - Montgomery
AL - Central Alabama VA Medical Center - Tuskegee
AL - Turscaloosa VA Medical Center
AR - Fayetteville VA Medical Center
AR - John L. McClellan Memorial Veterans' Hospital
AZ - Bob Stump Department of Veterans Affairs Medical Center
AZ - Carl T. Hayden Veterans' Administration Medical Center
AZ - Tuscon VA Medical Center
CA - Fresno VA Medical Center
CA - Jennifer Moreno Department of Veterans Affairs Medical Center
CA - Jerry L. Pettis Memorial Veterans' Hospital
CA - Martinez VA Medical Center
CA - Palo Alto VA Medical Center
CA - Palo Alto VA Medical Center - Livermore
CA - Palo Alto VA Medical Center - Menlo Park
CA - Sacramento VA Medical Center
CA - Tibur Rubin VA Medical Center
CA - West Los Angeles VA Medical Center
CO - Grand Junction VA Medical Center
CT - West Haven VA Medical Center
DC - Washington DC VA Medical Center
DE - Wilmington VA Medical Center
FL - Bruce W. Carter Department of Veterans Affairs Medical Center
FL - James A. Haley Veterans' Hospital
FL - Lake City VA Medical Center
FL - Malcom Randall Department of Veterans Affairs Medical Center
FL - Orlando VA Medical Center
FL - West Palm Beach VA Medical Center
GA - Carl Vinson Veterans' Administration Medical Center
GA - Charlie Norwood VA Medical Center
GA - Joseph Maxwell Cleland Atlanta VA Medical Center
HI - Spark M. Matsunaga Department of Veterans Affairs Medical Center
IA - Des Moines VA Medical Center
IA - Iowa City VA Medical Center
ID - Boise VA Medical Center
IL - Captain James A. Lovell Federal Health Care Center
IL - Danville VA Medical Center
IL - Edward Hines Junior Hospital
IL - Jesse Brown Department of Veterans Affairs Medical Center
IL - Marion VA Medical Center
IN - Fort Wayne VA Medical Center
IN - Marion VA Medical Center
IN - Richard L. Roudebush Veterans' Administration Medical Center
KS - Colmery-O'Neil Veterans' Administration Medical Center
KS - Dwight D. Eisenhower Department of Veterans Affairs Medical Center
KS - Robert J. Dole Department of Veterans Affairs Medical and Regional Office Center
KY - Cincinnati VA Medical Center - Fort Thomas
KY - Franklin R. Sousley Campus
KY - Robley Rex Department of Veterans Affairs Medical Center
KY - Troy Bowling Campus
LA - Alexandria VA Medical Center
LA - New Orleans VA Medical Center
LA - Overton Brooks Veterans' Administration Medical Center
MA - Brockton VA Medical Center
MA - Jamaica Plain VA Medical Center
MA - West Roxbury VA Medical Center
MD - Baltimore VA Medical Center
MD - Loch Raven VA Medical Center
MD - Perry Point VA Medical Center
ME - Togus VA Medical Center
MI - Aleda E. Lutz Department of Veterans Affairs Medical Center
MI - Battle Creek VA Medical Center
MI - John D. Dingell Department of Veterans Affairs Medical Center
MI - Lieutenant Colonel Charles S. Kettles VA Medical Center
MI - Oscar G. Johnson Department of Veterans Affairs Medical Facility
MN - Minneapolis VA Medical Center
MN - St. Cloud VA Medical Center
MO - Harry S. Truman Memorial Veterans' Hospital
MO - John J. Cochran Veterans Hospital
MO - John J. Pershing Veterans' Administration Medical Center
MO - Kansas City VA Medical Center
MO - St. Louis VA Medical Center - Jeffereson Barracks
MS - Biloxi VA Medical Center
MS - G.V. (Sonny) Montgomery Department of Veterans Affairs Medical Center
MT - Fort Harrison VA Medical Center
NC - Charles George Department of Veterans Affairs Medical Center
NC - Durham VA Medical Center
NC - Fayetteville VA Medical Center
NC - W.G. (Bill) Hefner Salisbury Department of Veterans Affairs Medical Center
ND - Fargo VA Medical Center
NE - Omaha VA Medical Center
NH - Manchester VA Medical Center
NJ - East Orange VA Medical Center
NJ - Lyons VA Medical Center
NM - Raymond G. Murphy Department of Veterans Affairs Medical Center
NV - Ioannis A. Lougaris Veterans' Administration Medical Center
NV - North Las Vegas VA Medical Center
NY - Bath VA Medical Center
NY - Brooklyn VA Medical Center
NY - Buffalo VA Medical Center
NY - Canandaigua VA Medical Center
NY - Castle Point VA Medical Center
NY - Franklin Delano Roosevelt Hospital
NY - James J. Peters Department of Veterans Affairs Medical Center
NY - Margaret Cochran Corbin VA Campus
NY - Northport VA Medical Center
NY - Samuel S. Stratton Department of Veterans Affairs Medical Center
NY - St. Albans VA Medical Center
NY - Syracuse VA Medical Center
OH - Chalmers P. Wylie Veterans Outpatient Clinic
OH - Chillicothe VA Medical Center
OH - Cincinnati VA Medical Center
OH - Dayton VA Medical Center
OH - Louis Stokes Cleveland Department of Veterans Affairs Medical Center
OK - Jack C. Montgomery Department of Veterans Affairs Medical Center
OK - Oklahoma City VA Medical Center
OR - Portland VA Medical Center
OR - Roseburg VA Medical Center
OR - White City VA Medical Center
PA - Abie Abraham VA Clinic
PA - Coatesville VA Medical Center
PA - Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center
PA - Erie VA Medical Center
PA - James E. Van Zandt Veterans' Administration Medical Center
PA - Lebanon VA Medical Center
PA - Wilkes-Barre VA Medical Center
RI - Providence VA Medical Center
SC - Ralph H. Johnson Department of Veterans Affairs Medical Center
SC - Wm. Jennings Bryan Dorn Department of Veterans Affairs Medical Center
SD - Fort Meade VA Medical Center
SD - Hot Springs VA Medical Center
SD - Royal C. Johnson Veterans' Memorial Hospital
TN - Alvin C. York Veterans' Administration Medical Center
TN - Lt. Col. Luke Weathers, Jr. VA Medical Center
TN - Nashville VA Medical Center
TX - Audie L. Murphy Memorial Veterans' Hospital
TX - Dallas VA Medical Center
TX - Doris Miller Department of Veterans Affairs Medical Center
TX - Garland VA Medical Center
TX - George H. O'Brien, Jr. Department of Veterans Affairs Medical Center
TX - Michael E. DeBakey Department of Veterans Affairs Medical Center
TX - Olin E. Teague Veterans' Center
TX - Sam Rayburn Memorial Veterans Center
TX - Thomas E. Creek Department of Veterans Affairs Medical Center
UT - George E. Whalen Department of Veterans Affairs Medical Center
VA - Hampton VA Medical Center
VA - Richmond VA Medical Center
VA - Salem VA Medical Center
VT - Burlington Lakeside VA Clinic
VT - White River Junction VA Medical Center
WA - Jonathan M. Wainwright Memorial VA Medical Center
WA - Mann-Grandstaff Department of Veterans Affairs Medical Center
WA - Seattle VA Medical Center
WA - VA Puget Sound Health Care System
WA - Vancouver VA Medical Center
WI - Clement J. Zablocki Veterans' Adminstration Medical Center
WI - Tomah VA Medical Center
WI - William S. Middleton Memorial Veterans' Hospital
WV - Beckley VA Medical Center
WV - Hersel Woody Williams VA Medical Center
WV - Louis A. Johnson Veterans' Administration Medical Center
WV - Martinsburg VA Medical Center
WY - Cheyenne VA Medical Center
WY - Sheridan VA Medical Center
VA Medical Center Name
*
VA Medical Center Street Address
*
VA Medical Center Street Address 2
VA Medical Center City
*
VA Medical Center State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Puerto Rico
Guam
American Samoa
Northern Mariana Islands
Virgin Islands, U.S.
US Minor Outlying Islands
VA Medical Center Zip Code
*
VA Medical Center Phone
*
Additional Information for Shipping
Use this space to alert Lingraphica to any changes needed to the address of your VA facility, add a specific name or department, office hours, etc.
Patient Information
Patient's First Name (or Initial)
*
Patient's Last Name
*
Date of Birth
Gender
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Female
Male
Pronoun
She/Her
He/Him
They/Them
Phone Number
How would you like us to contact the patient?
*
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Call
E-mail
Text (Mobile only)
By selecting "Text," you agree to receive SMS messages from Lingraphica. If you do not wish to receive SMS messages from Lingraphica, please choose a different contact method.
Does your patient have their own email address?
*
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Yes
No
Email
Enter Email
Confirm Email
Which language does the patient prefer to use when communicating with the Lingraphica team?
*
English
Spanish
Other
Please describe your patient's monolingualism or bilingualism
*
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English Only
Spanish Only
More English than Spanish
More Spanish than English
Balanced English and Spanish Proficiency
Other Languages
Medical Diagnosis
*
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Autism
ALS (Lou Gehrig's Disease)
Brain Tumor
Brain Injury
Cerebral Palsy (CP)
Dementia
Developmental Disorder/Delay
Dysphonia
Glioblastoma
Huntington’s Disease
Multiple Sclerosis
Multiple System Atrophy
Parkinson's
Primary Progressive Aphasia (PPA)
Progressive Supranuclear Ophthalmoplegia
Pseudobulbar Palsy
Stroke/CVA
Other
Please enter the diagnosis
*
Caregiver/Emergency Contact Information
Name of spouse, caregiver, or support person
Phone Number of spouse, caregiver, or support person
Email of spouse, caregiver, or support person
Enter Email
Confirm Email
Relationship to the Patient
Spouse
Parent
Child
May we reach out to the caregiver/communication partner?
*
Yes
No
Not yet
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