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Tele-assessment for Persons with Communication Disorders (Speech-Language disorders only)
Department of Clinical Services, AIISH, Mysuru.
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* Indicates required question
Name of the client
*
Your answer
Gender of the client
*
Female
Male
Other:
Required
Date of birth
*
MM
/
DD
/
YYYY
Parents/Caregiver Name
*
Your answer
Occupation
*
Your answer
Income/month
*
Below Rs. 10,000
Rs. 10,000- 20,000
Above 20,000
Required
Address
*
Your answer
Mother tongue
*
Your answer
Languages spoken
Kannada
Hindi
Malayalam
Tamil
Telugu
English
Other:
Mobile number
*
Your answer
Email
*
Your answer
Purpose
*
Tele-assessment
Required
Complaint
*
Your answer
Registration charges - 40/- Pay using the following QR Code. Payment to be made from Monday to Friday from 9:00 AM to 5:30 PM Only(Except on central government holidays)
Transaction ID
*
Your answer
Declaration:
1) I hereby declare that the information furnished above is true to the best of my knowledge.
2) I hereby consent and authorize the institute to perform the assessment procedures.
3) I agree to pay the registration charges of Rs. 40/- which is non refundable and also other detailed evaluation charges after preliminary assessment
4) I am aware that the Tele-assessment would be carried out on appointment basis only.
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