Hearing Loss & Cochlear Implant Counseling Intake Form

Support Your Deaf and Hard of Hearing Clients with a Professional Intake Form

Whether you're an audiologist, hearing loss counselor, or cochlear implant specialist, understanding your client's unique hearing journey is essential to providing personalized, effective care. This Hearing Loss & Cochlear Implant Counseling Intake Form is designed to capture the comprehensive background you need—from hearing history and communication preferences to cultural identity and assistive technology use.

Why This Template Works for Audiology & Hearing Loss Counseling

This Paperform template goes beyond basic patient information. It explores the full spectrum of hearing loss experiences, including:

• Detailed hearing history: onset, progression, and diagnosis details
• Communication barriers and preferences: spoken language, sign language, lip reading, and preferred modes
• Deaf and hard of hearing identity: cultural considerations that impact care
• Assistive technology assessment: hearing aids, cochlear implants, captioning devices, and more
• Psychosocial impact: emotional well-being, relationships, and support systems

The form uses conditional logic to adapt questions based on responses, ensuring you only ask relevant follow-up questions. This creates a more personalized experience for your clients while streamlining your intake process.

Streamline Your Practice with Paperform + Stepper

Paperform makes it simple to customize this template to match your practice's branding and workflow. Embed it on your website, send it via email before appointments, or use it as a standalone landing page. All submissions are securely stored and can sync directly to your EHR, CRM, or practice management software.

Take your automation further with Stepper—route new intakes to the right specialist, trigger appointment reminders, update patient records automatically, or create customized care plans based on responses. You can even use Papersign to collect consent signatures on treatment agreements or HIPAA forms seamlessly.

Trusted by Healthcare Professionals

With SOC 2 Type II compliance, robust data security, and GDPR readiness, Paperform provides the professional infrastructure you need to handle sensitive patient information responsibly. Thousands of healthcare providers, therapists, and counseling practices trust Paperform to deliver intake experiences that feel personal, professional, and secure—without the need for developers or IT teams.

Start using this template today to better understand your clients' hearing journeys and deliver more effective, compassionate care.