REV 6/16

for Parkinson’s Disease & Movement Disorders

LSVT LOUD®

Program

Referral FormLSVT LOUD® Program for Parkinson’s Disease & Movement Disorders (Physician use only)

Date: ____________________________________________________

Patient Name: ____________________________________________

Patient DOB: _____________________________________________

Patient Phone: ___________________________________________

Diagnosis: _______________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

ICD-10: __________________________________________________

Date of Onset: ___________________________________________

Referred to ENT for Evaluation: 9 Yes 9 No

Date: ____________________________________________________

Precautions/Comments: __________________________________

Order: __________________________________________________

Outpatient speech and language pathology for LOUD® standardized treatment protocol or as recommended by therapist

Physician Name (please print):

_________________________________________________________

Physician Signature:

_________________________________________________________

Phone: __________________________________________________

Fax: _____________________________________________________

Return to:LSVT LOUD® Program

Outpatient Rehabilitation Services

VirginiaPage Memorial Hospital

Outpatient Rehabilitation Services200 Memorial Drive • Luray, VA 22835540-743-8052 • FAX: 540-743-8054

Shenandoah Memorial HospitalOutpatient Rehabilitation Services

759 S. Main Street • Woodstock, VA 22664540-459-1164 • FAX: 540-459-7126

Warren Memorial Hospital Outpatient Rehabilitation Services

Warren Memorial Hospital Outpatient Center120 N. Commerce Ave. • Front Royal, VA 22630

540-635-0730 • FAX: 540-636-7126

Winchester Medical CenterOutpatient Rehabilitation ServicesValley Health Wellness & Fitness Center

401 Campus Blvd. • Winchester, VA540-536-3011 • FAX:540-536-3032

West VirginiaWar Memorial Hospital

Outpatient Rehabilitation Services261 Berkmore Place, Suite 2A Berkeley Springs, WV 25411

304-258-8377 • FAX: 304-258-8871

LSVT LOUD®

LSVT LOUD® is a research-based voice/speech treatment program that was specifically developed for individuals with Parkinson’s disease and other movement disorders. A standardized treatment pro-tocol is administered by a certified LOUD therapist to help patients achieve improved voice and speech function.

Getting Started

Request a referral for therapy from your primary care physician or neurologist.

Your physician will refer you to an otolaryngologist (ear, nose and throat specialist), who will conduct an evaluation and provide clearance for your partici-pation in the LSVT LOUD® program.

Once the evaluation is completed, call the outpatient rehabilitation location closest to you to schedule your appointment. Please let the scheduler know your referral is for the LOUD® program. You will be scheduled with one of our specially trained speech therapists for evaluation and to begin treatment.

See the back of this brochure for a full list of partici-pating outpatient rehabilitation locations.

LSVT LOUD® Treatment

LSVT LOUD® treatment consists of 16 sessions: four days a week for four weeks. Each session is approx-imately 60 minutes in duration. It is imperative that you attend each of these appointments, as they progressively build on one another.

In addition, you will receive a series of exercises to be completed at home for 15-20 minutes each day. These exercises are essential to establishing improved function. Custom exercises will be used to increase the respiratory, laryngeal and articulatory function needed to maximize speech intelligibility. The goal is for you to have improved, healthy vocal loudness with no strain.

Follow-Up

Every six months to one year we suggest that you come back for a re-evaluation or “tune-up.” This will allow the speech therapist to reassess your perfor-

mance and compare it to your previous discharge status. We will work together to ensure you are generating an adequate amount of loudness to make your speech clear and easy to understand. Parkinson’s is a progressive disease, and these “tune-ups” will allow us to continue to be your partner on this journey.

If you think the LOUD® program can benefit you, ask your physician for a referral. Once you have been evaluated by an otolaryngologist (ear, nose and throat specialist) and cleared for the LSVT LOUD program, call to make an appointment at the outpatient rehabilitation location that is most convenient for you.

I completed the LSVT LOUD® program offered by Valley Health Rehabilitation Services and can’t thank my speech therapists enough for helping me regain my speech, swallowing abilities and self-confidence. Through their positive feedback, encouragement and inspiration I am now able to increase my speech volume and clarity.

- Llew Galway