Student Introduction Form

Student Introduction Form

Name of Student*

Date*

Discipline*

SLP

What are your interests in this facility, both generally and specific to different patient populations?*

List 3 objectives you hope to achieve through this clinical experience.*

What are your strengths, and how will they make you successful in the acute care setting?*

What are areas that you feel need strengthening?*

What are your past experiences in rehabilitation? (sites, populations, age groups etc.)*

Please describe a challenging session or patient/family interaction that you've experienced, and how you handled it.*

Do you require any accommodations for this clinical placement? If so, describe the accommodations needed.*

Are you interested in acute care pediatrics?*

Select

What is your comfort level when working with premature/neonates, toddlers, school aged, teenagers, young adults? Please describe any previous experiences with these age groups (can be non-medical), including both rewarding and challenging aspects.*

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