Internal Professional Benefit Check

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Internal Professional Benefit Check

Who is completing this intake?*
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Persona*
Sales Channel*
Previous Trial Information
Have you previously conducted a Lingraphica device trial?*
- Yes
- No
Do you prefer to work with your previous Clinical Consultant?*
To provide the best trial experience, we will do our best to pair you with the Lingraphica Clinical Consultant who will meet your trial’s needs. Including accommodations for Spanish-English bilingualism and Spanish speakers.
- Yes
- No preference
- No, I want to work with -(select CC)-
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archived_ Do you currently have a trial AllTalk, TouchTalk, or MiniTalk?
- Yes, I have a device and will use it with this patient.
- Yes, I have a device but need another for this patient.
- No, I don't have a device.
SLP Information
SLP Name*
First Last
Do you use your mobile phone, work phone, or both?*
- Mobile Phone
- Work Phone
- Both
Work Phone Number
Extension
Mobile Phone Number
Email*
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What language do you prefer to speak when communicating with Lingraphica?
- English
- Spanish
- Other
How would you like us to contact you?*
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.
How long do you expect to have this patient on caseload?*
- 1 week or less
- 1-2 weeks
- 2 weeks or more
- Uncertain (Visits depend upon continued authorizations)
- I don't know
Which Lingraphica Communication Device would you like to trial?*
All of Lingraphica's communication devices have the same software. The only difference is size. To learn more about our devices, visit https://lingraphica.com/aac-devices/
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archived_Which Lingraphica Communication Device will you be using with this patient?
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archived_Serial number of your current trial device
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://www.aphasia.com/aac-devices/aac-device-accessories.
- Standard Mouse (Wireless)
- Joystick w/switch
- Stylus Tether
- Wireless Keyboard
- Keyboard Large Print
- Ball Stylus
- Extended Stylus
- T Stylus
- Weighted Stylus
- Flexible Stylus with Strap
- Long Flexible Stylus
- None (all devices come with a standard case and stylus)
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://www.aphasia.com/aac-devices/aac-device-accessories.
- Standard Mouse (Wireless)
- Joystick w/switch
- Stylus Tether
- Wireless Keyboard
- Keyboard Large Print
- Ball Stylus
- Extended Stylus
- T Stylus
- Weighted Stylus
- Flexible Stylus with Strap
- Long Flexible Stylus
- None (all devices come with a standard case and stylus)
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Will you need any additional accessories for this trial? (Choose up to 2 (two))
Select "No" if you do not wish to order additional accessories for this trial.
- No
- Standard Mouse (Wireless)
- Joystick w/switch
- Stylus Tether
- Wireless Keyboard
- Keyboard Large Print
- Ball Stylus
- Extended Stylus
- T Stylus
- Weighted Stylus
- Flexible Stylus with Strap
- Long Flexible Stylus
Shipping Information for Trial Device or Information Packet
Please note: We recommend trial devices be shipped to the SLP. If you request shipping to a client or another recipient, please confirm they’ve been notified. The SLP completing the intake is responsible for the device until it is returned to Lingraphica.
Facility Name
Country*
Street Address*
Street Address 2
City*
State*
State / Province*
Zip Code*
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Special Instructions for Shipping
What made you think of Lingraphica for this patient?*
Please explain what made you think of Lingraphica.*
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?
Are you interested in scheduling a virtual in-service with a Lingraphica representative?*
- Yes
- No
Patient Information
Patient's First Name*
Patient's Last Name*
Date of Birth*
Gender*
Pronoun
- She/Her
- He/Him
- They/Them
Phone Number
How would you like us to contact the patient?
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.
Alternative Phone Number
Does your patient have their own email address?*
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*
In which clinical setting are you currently treating your client?*
This is the location you will work with your client
Where does the patient currently reside?*
This is where the patient lives permanently
Name and/or Type of Facility
Approximate Discharge Date
MM slash DD slash YYYY
Where will the patient reside when they are discharged?
Country*
Street Address*
Street Address 2
City*
State*
State / Province*
Zip Code*
Medical Information
Medical Diagnosis*
Enter your client's diagnosis or medical abbreviation below and select the option that most closely matches
If needed, enter additional diagnosis details
Speech Diagnosis*
- Aphasia
- Apraxia
- Dysarthria
- Other
ICD-10 Code
Date of Onset*
Is the medical diagnosis the result of an accident?*
- Yes
- No
Date of Accident
Is the insurance covering treatment for the medical diagnosis a liability insurance?*
- Yes
- No
Type of liability insurance (ex. Auto / Workers Compensation)*
What is the patient's physician's first and last name?
Phone number for their physician
Has the patient ever owned a communication device?*
- Yes
- No
When did they purchase the communication device?*
Did their current insurance company pay for the communication device?*
- Yes
- No
Is the patient receiving hospice care?*
- Yes
- No
Primary Insurance Information
Would you like to upload a photo or scan of your patient's primary insurance card?*
- Yes
- No
Primary Insurance Card*
Drop files here or

Max. file size: 40 MB.
You can upload photos or scans of your insurance card. Please upload the front AND back of your insurance card.
What is the patient's primary insurance?*
Member ID/Policy Number*
Group Number
Insurance Provider Hotline Phone Number
What is the patient's relationship to the policyholder?*
Name of Policyholder*
Policyholder's Date of Birth*
Does the patient have secondary insurance?*
- Yes
- No
Secondary Insurance Information
Would you like to upload a photo or scan of your patient's secondary insurance card?*
- Yes
- No
Secondary Insurance Card*
Drop files here or

Max. file size: 40 MB.
You can upload photos or scans of your insurance card. Please upload the front AND back of your insurance card.
What is your secondary/supplemental insurance?
Secondary/Supplemental Insurance Member ID/Policy Number
Secondary/Supplemental Insurance Group Number
Secondary/Supplemental Insurance Phone Number
What is the patient's relationship to the secondary insurance policyholder?
Name of Policyholder
Policyholder's Date of Birth
Financial Information
This information will be used to provide you with the most accurate estimate of any potential out-of-pocket costs. Please be as accurate as possible; however, estimates are acceptable. These questions are optional but highly recommended.
Family/Household Size
Total Household Monthly Income
Total Household Monthly Expenditure
Please include all household expenses such as mortgage/rent, utilities, medical expenses, etc.
I hereby acknowledge that the information given herein is true and correct
- ACKNOWLEDGED
Care Partner or Support Person Information
Lingraphica will need to communicate with either the client or their care partner/support person throughout the trial process. Communication with your client's support system increases the likelihood of a positive and successful trial experience.
Who should we reach out to about the device trial?*
Are they aware of the device trial?*
Are they aware of the device trial?*
Describe your client's support system during the trial*
How does the care partner feel about the device trial?*
Name of spouse, caregiver, or support person
Phone Number of spouse, caregiver, or support person
Email of spouse, caregiver, or support person
Relationship to the Patient
- Spouse
- Parent
- Child
When can we reach out?
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Is the caregiver the patient's legal guardian or Power of Attorney?
- Yes
- No
- I don't know
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How would you like us to contact them?
What language does the primary caregiver/communication partner prefer to use when communicating with Lingraphica?
- English
- Spanish
- Other
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May we reach out to the caregiver/communication partner?*
- Yes
- No
- Not yet
Please confirm your trial shipping information*
- By checking this box, you confirm the shipping address provided is yours (the practicing clinician), that the address is correct and someone will be there to sign for the package.
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Other Comments or Notes

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Internal Professional Benefit Check

Previous Trial Information

SLP Information

Shipping Information for Trial Device or Information Packet

Patient Information

Medical Information

Primary Insurance Information

Secondary Insurance Information

Financial Information

Care Partner or Support Person Information