Section Five
Module 16: Preparing for Multi-Cultural Clinical Service Delivery
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What must be in place before we interact with our clients?
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After working with the material in this module, readers will be able to
create clinic websites that are accessible, inclusive, and respectful of all persons’ cultural and personal backgrounds and identities
create clinical intake forms that are accessible, inclusive, and respectful of all persons’ cultural and personal backgrounds and identities (cf. ASHA Certification Standard IV-C, and in preparation for practicum assignments addressing Standard V-B)
create physical clinical spaces that are accessible, inclusive, and respectful of all persons’ cultural and personal backgrounds and identities
create online or virtual clinical spaces that are accessible, inclusive, and respectful of all persons’ cultural and personal backgrounds and identities
Multi-cultural clinical practice starts before we meet our clients. People interact with us through our websites, our intake forms, our physical spaces, and our virtual or online clinical spaces, all of which need to be accessible and welcoming for everyone.
Be sure you understand the distinctions between “multi-” situations and “cross-” situations, and the constructs of universal needs and specific needs, from Module 15, before you try to read this module.
Multi-Culturally Welcoming Webpages
What do your potential clients see, when they first click onto the first page of your website? Websites and webpages are complex structures with many elements. For our purposes, we can focus on only five.
Content refers to the information itself and to the visual and auditory elements that are used to present that information. If you are trying to convey the location of your office, the relevant content on your webpage might include your address shown in printed words, a description such as “near the 12th Street YMCA in Midtown,” or an image of a map with your location marked.
Function refers to the goal of any page, screen, section, menu, item, or link. The goal of one section on one page might be to provide information about you or about your services; the goal of the button at the top might be for clients to send you a message or schedule a free initial consultation with you.
Design or style refers generally to the overall look and feel of the site: the colors, fonts, images, sounds, and resulting emotional reactions. Some webpages use bright colors, lots of white space, and photographs of smiling people; others use dark colors, dark images, dark sounds, and images of angry faces.
Accessibility asks whether users can interact with the website in a way that allows the intended information to be communicated and the intended function to be achieved. A webpage’s visual content is accessible if people can see it; it is inaccessible if the fonts are too small, the colors are too muddy, or advertisements cover half the page. A website is accessible, as a whole, if all the information is available to people who use either vision or hearing but not both, and if all the functions of the webpage can be achieved by people with a range of physical, cognitive, and other abilities.
Inclusion asks about potential users’ emotional experiences with the site, or to the group of people that the website is aiming to create. Your goal might be to present information about your practice to everyone in your community in a way that draws people in and makes them feel that your clinic will be welcoming and helpful for them. Inclusion refers to whether your website achieves this goal.
Many of these aspects of web development and design will be handled for you by your web hosting service or website building software, or by your colleagues in an information technology office at the district level or for the entire hospital system. Nevertheless, it is important for each of us to be aware of these issues, in part because the website services and products we use must meet legal accessibility requirements (related to being part of a state or local government entity or a business serving the public, from Module 3; see also the information about web accessibility under the Americans with Disabilities Act provided at the ADA.gov website). Most importantly, and most generally, the law requires that our professional websites be constructed such that the information and the intended function of each element are equally accessible to all users, including people with the full range of human abilities in the visual, auditory, cognitive, and motoric realms.
Multi-cultural, universally appropriate, client-centered clinical practice starts before we meet any of our clients and encompasses everything about our clinical infrastructure, or the online or physical background within which we work.
Your clinic’s website might be the first interaction that your clients will have with you, so let’s start there.
Given these issues, you will need to think about visual, auditory, cognitive, and motoric abilities as they interact with the website’s content, function, design, accessibility, and inclusion, any time you are working on any part of any clinical website.
Visually, for example, you might need shorter paragraphs, larger fonts, and fewer non-functional decorative elements. Use color contrasts that people with different levels of color vision can perceive (avoid red on green or vice versa, and avoid blue on yellow or vice versa). Use sharp contrasts throughout (one of my own routine visual complaints, because of my own visual abilities, is what I refer to as web designers’ illegible “grey on grey” color choices). Take the time to write complete and meaningful alternative text for all photos, pictures, and other visual elements; if you allow an AI or natural-language computer system to create your first draft of such text, read it and fix it. And be aware of how your webpages will function with text-reading software or if they have been zoomed in or otherwise adjusted for visual accessibility; experiment with the accessibility settings on your phone and your computer, if you have never had reason to use them (or try reading your webpages with your sunglasses on and with the screen’s brightness turned to its lowest level, if your vision is not usually limited).
Auditory, cognitive, neuropsychological, and motoric abilities require similar considerations. Auditorially, one common problem is missing or inaccurate captions for videos; again create and check your own, rather than depending on automatic captions.
Think also about the function and the accessibility of your website for people who find it easier or harder to ignore extra links, noises, or visual materials and for people who will be frightened or distracted by sudden flashes or noises. Draw on your knowledge of alternative and augmentative communication systems, draw on your knowledge from your collaborations with occupational and physical therapists, and imagine users who have a wide range of motoric abilities and who will be accessing your website using a range of technologies.
In addition, as you create the content and the style of your webpage or website, be aware of the overall message that your choices are communicating to all users of your website. If your intent is a multi-cultural site that will feel equally safe and equally welcoming to “all populations” (as required for us by ASHA, 2017; see Module 3), then your photos, symbols, styles, and colors need to convey and respect a wide range of human possibilities without falling back on any tokenism or stereotypes (a topic we will address in more detail below for our physical and virtual clinical spaces).
And the specific words we include on webpages, of course, also convey our multi-cultural inclusivity and respect. Some words are legally required: If you are a covered entity under HIPAA or subject to other federal regulations, you must provide the current prescribed nondiscrimination statement (see Module 3, and use the U.S. Department of Health and Human Services website for current guidance and the required format of the statement).
Well beyond the legal minimums, multi-cultural websites are also phrased to be positive and inclusive throughout. Person-first language remains the generally preferable default for a website intended for the general public, so I still recommend person-first language on general clinical websites (even though some groups are rethinking this advice or using identity-first descriptors as pride language for themselves). We also seek to describe abilities, backgrounds, and identities in positively framed ways. If you list the services you provide, for example, try “Services available to help all people of all ages with speech, voice, language, and social communication” rather than “Services for speech disorders, voice disorders, and language disorders.”
And because we welcome all clients from all backgrounds, use explicit words on your website to say so; include a phrase such as “We welcome inquiries from everyone” or “All clients from all backgrounds and with all individual identities are welcome at Sunflower Speech Therapy.”
Your Turn
Analyze your school’s, hospital’s, or practice’s website. Use the ideas from this segment and other information from throughout this website. Does your website recognize, respect, and respond to the many cultural and individual dimensions we have been addressing? How might an architect or another person with skills in universal design change your website, if that person were approaching your website as a product to be developed according to their principles?
Web design and programming professionals distinguish among accessible web design, inclusive web design, and universal web design in several overlapping ways. Try searching online for several definitions of these terms, for websites and programming, and comparing them to each other. How do the different definitions you found relate to our basic emphases on recognition, respect, and responsiveness for all human dimensions, backgrounds, abilities, characteristics, and identities? Does what you found lead you to think any differently about “multi-”, “cross-”, “transcultural,” or “universal design” (from our Module 15)?
How do the characteristics described in this segment for our practice webpages also apply as we provide communication care via online video conferences?
Multi-Cultural and Identity-Affirming Intake Forms
The next step that a potential client might take with you, also potentially before you have met them in person (or in a real-time video conference), will often be to fill out a shorter or more comprehensive intake form. How should we design our intake forms, if our goal is client-centered, culturally and individually appropriate speech-language pathology?
Intake forms are written surveys (either on paper, electronic, or online) that begin our attempts to build a personal relationship with a future client, but they are designed and used at stages where we know almost nothing about that client. Like our websites, therefore, intake forms must be multi-cultural, focusing on universals more than on specifics, and appropriate for everyone who completes them. Intake forms are not individually designed bridges that carry us directly to a single client; they are multi-purpose tools.
Intake forms, therefore, must reflect our awareness that people from all cultures, with the full range of human abilities and with all identities, will be trying to complete them. Our intake forms are built on our awareness of and respect for the many dimensions, continua, and options that characterize both groups and individuals.
If you are creating or revising intake forms for yourself or for your practice, consider all of the questions summarized in Box 16.1, and discussed in greater detail below, as you design your forms and their questions.
Box 16.1. Culturally and Individually Appropriate Considerations as We Design Clinical Intake Forms
Toward which healthcare or educational function am I asking this question?
Do I need that information from everyone?
What other information do I need?
Does everyone have that?
Is everyone’s answer among the options?
Am I asking this question in way that reflects my respect for all possible answers?
Which languages do I need my forms in, for this community?
Will everyone who completes this form have approximately the same emotional experience with it?
Think about each of the questions presented in Box 16.1. Do you see why each one matters, or how each one can help us think through what we are asking people to do before we meet them?
One of the first principles of survey design is to understand the purpose of the survey and of each question on it. In speech-language pathology intake forms, we seek information from potential clients for the purposes that HIPAA summarizes as treatment (i.e., client care, including screening, assessment, and intervention), payment, and our own internal healthcare business operations. As you design a form, therefore, it can help to be sure in your own mind which of these purposes the form as a whole is meant to address and the purpose each question is meant to address. Some information is necessary. But if your answer is that this information does not help you serve the client, or that you might need the information to understand some clients’ experiences and needs, then think carefully about why you are asking every client. Every question on your intake form is essentially a hurdle that clients must leap before they are allowed to see you. Make sure it’s a necessary hurdle for everyone, before you set it up in front of anyone.
At the same time, we are also thinking “What did I not think to ask that I should have asked?” or “What other information do I need?” Use Morgan’s (1996) axes of identity from Module 2 to think through any information your forms might be missing that you do need from every client to be able to serve them appropriately. Reasonable additions or changes to common forms might include asking about all languages and dialects the client and the family would like to incorporate into their services (see Section Two; this is very different from asking for the client’s primary language or asking clients to name only one of their languages as a single language used at home).
Thinking “Does everyone have that?” and “Is everyone’s answer among the options?”, next, helps us recognize any limitations in our own imaginations. Based on our recognition and respect of the full range of family structures and living situations, for example, our forms do not ask for a child’s “mother’s name.” We ask instead for the name, contact information, and relationship to the child of the person filling out the form, or we ask for similar information for up to 3 or 4 adults who share responsibility for the child and will be involved in the child’s care. Similarly, we probably do not need to ask for every client’s physician, religion, or marital status; these questions can be important as you build specific bridges later, but they are not among the first information you must have about a person, and asking them often manages to do little more than alienate people who do not believe in westernized medicine, do not practice an organized religion, or have lived through some very complex times as societal expectations about human relationships have changed.
For the questions you do need to ask, think carefully about how clients will answer. Multi-culturally appropriate forms use open-ended questions, with blanks for the client to fill in, rather than checkboxes or drop-down suggestions that divide people into those who fit into one of the “correct” categories and those who are “othered” by the form.
A system of checkboxes, whether on paper or on a computer screen, might initially seem more expedient for clients or for staff, but it is only easy for clients whose answer is at the top of the options, clients who see well, clients whose attentional abilities allow them to scroll long lists, and clients whose motor abilities allow them to select precisely from within a long list. (If you live in Alabama or Wyoming, you have a different experience with clicking your state in an online form than people in Mississippi and Missouri have.) It is much easier for a client to write an answer to the open-ended question “How would you like us to address you?” than it is for that client to search through the boxes for “Title” that include Mr., Ms., Mrs., Miss, Mx., and Doctor, pause, and ultimately click “Other” and write “Abbie,” “Rabbi Avril,” or “Colonel Aragón.” The goal of multi-cultural practice is to do our best to recognize, respect, and respond to all potential clients’ needs by thinking about human universals, not by trying to list all the specifics. Be sure you are not designing a form that will metaphorically be asking everyone to climb over all the bridges you were trying to build to other people. (Most of us who live in mid-alphabet states have learned to get around the 50- or 52-item checklist by typing our state’s abbreviation; it’s faster.)
On the whole, your intake forms have several goals. They should be starting to gather the information you will need to begin developing a therapeutic relationship with this client (or to begin the process of determining whether one is needed). They should be easy for anyone to complete, regardless of that person’s cultural or personal identity or background. And everyone who has completed your multi-culturally appropriate intake form should come away feeling that you care about their individual answers and are prepared to meet their needs as a unique, respected, and worthwhile human being.
One more note: Be aware that shorter, more focused instruments meet the needs of clients with a wide range of language, cognitive, visual, motor, and other abilities. They are also more likely to provide you with more complete and therefore more useful information (because respondents are known to provide more valid and more reliable responses to shorter surveys than to longer ones). Multi-cultural, accessible, inclusive intake forms will probably be structured as a series of shorter forms, each designed to focus on one type of information (client care, payment, or our own internal operations), not as one overwhelmingly long instrument.
Your Turn
Analyze one or more of your clinic’s intake forms. Use the questions in Box 16.1 and other information from throughout this website. Were your intake forms designed in a way that recognizes, respects, and responds to the many cultural and individual dimensions we have been addressing? How might an architect or another person with skills in universal design change your intake forms, if that person were approaching your intake form as a product to be developed according to their principles?
Function and Décor for Physical (and Virtual) Spaces
You are finally meeting some clients! If they have successfully navigated your website, your appointment processes, and your intake forms, your clients will then meet you, either in your physical space or in a real-time videoconference. Let’s think again about content, function, style, accessibility, and inclusion.
Function of the Space
At the basic level of both content and function, your physical and virtual entry and waiting spaces need to serve the universal purposes of entry and welcoming, both physically and emotionally. Similarly, your clinical or intervention spaces, both physical and virtual, need to serve the universal purpose of facilitating client-centered, family-centered, whole-person communication care. They need to do so for a wide range of people, including those whose cultural backgrounds differ from each other’s and from yours, and including for those whose abilities and needs in the areas of mobility, vision, hearing, problem-solving, attention, visual or auditory (over)stimulation, need for other people, and fear of other people might differ from your individual preferences or initial assumptions.
Think first about a physical entry or waiting space. Depending on the location or style of your practice, you might start by considering all of the ideas listed in Box 16.2 (many of which are related to the notion of trauma-informed care; see Module 19).
Box 16.2. Functional Characteristics of Universally and Multi-Culturally Welcoming Clinical Entries or Waiting Spaces
Large simple signage, easily visible from the street, parking lot, or elevator lobby
A physically accessible front door that a person in a wheelchair, a person moving slowly with a cane, or two or more people assisting each other physically can manage
A well-lit front door with no overgrown bushes or potentially frightening shadows
Minimal but clear signage inside about where to check in
A two-level check-in desk or counter that is high enough for tall adults and low enough for people in wheelchairs, arranged to allow privacy for individual clients and also with enough space to be welcoming to couples or families who come in together
Space in the waiting room for persons with wheelchairs, strollers, or service dogs to maneuver, and for people afraid of or allergic to dogs to avoid them
Chairs of different sizes, including some that are sturdy enough for relatively large people and some that are smaller and with strong arms to help older people push themselves up
Clear line-of-sight and clear pathways between and among your entry door, your check-in counter, your waiting chairs, and the entry to your treatment spaces (to allow physical mobility without tripping hazards; to give clients the emotional safety of knowing what will happen next and knowing how to get out; to allow clients with children to see them at all times; and to allow clients with vision, hearing, or speech concerns to know that you are calling them and to respond in a way that you can see if you cannot hear their response)
Enough light, no unnecessary sounds, and no clutter on the walls, counters, or tables (to reduce anxiety in clients with a range of neuropsychological abilities)
In addition to the suggestions provided in Box 16.2, be aware that television monitors have become ubiquitous in most waiting rooms but can be problematic. It is almost impossible to ensure that the images on the screen will be consistently welcoming and appropriate for everyone, and the extra visual and/or auditory noise will compete with necessary conversations, especially for your clients with hearing, attention, or anxiety issues.
Do you also see that the issues for virtual waiting rooms are surprisingly similar to those listed in Box 16.2 for physical spaces? Physical space for wheelchairs might not be not relevant online, but most of the other needs described in Box 16.2 are the same for your online videoconference’s start-up page or virtual waiting room as they would be for a physical space: Where clients are and what to do next needs to be clear, and the overall feel needs to be universally welcoming to all clients.
Most of the basic functional requirements for our physical assessment and treatment spaces are also similar to those listed for waiting rooms. Be aware, in particular, of the need for enough chairs, tables, and other work spaces (such as carpet squares for children) of different sizes, and also the need for enough open space for wheelchairs and walkers. Your physical clinical spaces need enough light that people can see, a way to tone down the light for individuals who are bothered by bright light, no unnecessary sounds, no unnecessary clutter, and both an obvious means of exit for anyone who needs out and also a safe way to keep children from escaping on their own. Your virtual clinical spaces need exactly the same things: a simple and universal focus on safe and welcoming interactions with you.
You might have noticed that medical offices tend to be more sparsely furnished and more neatly kept for infection-control reasons than independent clinics and school-based spaces. If you work in a physical space other than a medical space, consider emulating your medical colleagues. You might buy more storage bins, or another large cabinet, to minimize the visible clutter that clients need to physically maneuver around, that clients with attention or anxiety issues need to cognitively work through, and that children will only be tempted by.
Decorating the Space
After the functional elements of your space are in place, then you can consider its style, or how to decorate it. In a physical space, you might decide about paint colors, upholstery, art for the walls, or which toys or magazines to leave in the waiting room. For a virtual space, you will decide what to use as your electronic background images. For either modality, if your goal is a multi-cultural space that feels equally welcoming and equally physically and emotionally comfortable to everyone, reasonable options include seeking actively to be as inclusive as possible or decorating by seeking “everyone’s second choice.”
To be actively inclusive, for example, you might choose several different fabrics for your chairs; hang several photographs that all show people who seem to be of many different races, ethnicities, and genders playing different sports together; and also hang several different photographs that all show people who seem to be of many different races, ethnicities, and genders playing a range of musical instruments together. Be careful to actively avoid stereotypes, as you make these style choices. The goal is not to show that some people who look like this should play soccer, while other people who look like that should play cello; the goal is to show that all people can do all things.
Alternatively, it is often simpler to fall back on “everyone’s second choice,” or to find something bland that you hope everyone will find acceptable. This approach is a variation on seeking the universal, and it is a compromise solution to a potential conflict (see Module 26). “Everyone’s second choice” decorating decisions lead to the many perfectly acceptable pale blue clinic walls in the world with abstract art or generic landscape or cityscape photographs. They are no one’s favorite, but they reflect reasonable attempts at universal decisions that most people will perceive in approximately the same way and that actively exclude no one.
For physical clinical spaces, the same principles also apply to any other physical objects you might choose to incorporate.
If you choose to provide reading material in your waiting room, for example, try thinking universally and in creatively multi-purpose ways. Selections from the many available lists of international wordless picturebooks for children, as one option, can be among the best choices for (almost) everyone, because of their intentional breadth. They might not be your very own first choice, but they can be a simple way to select one option that meets most people’s underlying need to be occupied and calmed for a few minutes (i.e., it’s a universal design decision). The International Board on Books for Young People maintains lists of its recommended international wordless picturebooks, which do not require familiarity with any language or dialect, as well as books that are either for or about people with a range of physical and cognitive abilities. You could also select a range of different books from a source such as the Social Justice Books project.
One last note: Let’s avoid religious and political materials and symbols entirely (see Module 25), and let’s avoid anything intended to be frightening, even if you think of it as “fun scary.” We will make unintentional mistakes (see Module 26), but multi-culturally appropriate decoration seeks, as a general rule, to be universally welcoming and inclusive for everyone, not divisive, challenging, playing favorites, or in any way frightening to anyone.
Your Turn
Think about the functional elements and the decorative elements of any clinical waiting room, clinical space, or any other business that has been new to you recently. Did you feel good when you entered the space for the first time? What examples did you see of universal design principles used well (decisions that seem to have been intended to meet higher-order, category-level, human needs in creative ways that were not tied to any one specific preference)? What might you have changed about that space, either in function or in decor?
Think about the functional elements and the decorative elements of your own physical clinical spaces and virtual clinical spaces. Do you know what your video-conference software’s virtual waiting page looks like? If you provide online therapy, have you worked to make your virtual background and other decorative elements seem universally welcoming to all populations from all backgrounds? If you have a physical space, would anyone from anywhere in your entire geographic area feel comfortable walking in your door?
Do your physical and virtual clinical spaces convey your own preferences or do they seek to make all new clients from all backgrounds feel welcomed and comfortable? I am prepared to guess that the answer is “a little bit of both”! Look around your spaces, and discuss any changes you might like to make.
I was in a clinic’s waiting room with my elderly mother recently that she perceived as “depressing” and I perceived as “pale gray.” If pushed, I might have described it as “not pretty, but they were attempting to be calming.” Is there anything the room’s designer could have done to make us both feel good in that space? How can clinic decor serve as a metaphor for the distinctions among multi-cultural work, cross-cultural work, human universals, and individuals’ specific preferences?
Highlight Questions for Module 16
Explain some of the characteristics of accessible, inclusive, respectful, universal, or multi-culturally welcoming webpages. Why do our clinical webpages need to reflect these characteristics?
Explain some of the characteristics that make clinical intake forms accessible, inclusive, and respectful of all persons’ cultural and personal backgrounds and identities. Why do our intake forms need to reflect these characteristics?
Explain some of the characteristics that make physical and virtual waiting rooms and clinical spaces accessible, inclusive, and respectful of all persons’ cultural and personal backgrounds and identities. Why do our physical spaces and our online clinical spaces need to reflect these characteristics?
Discuss any differences you perceive between physical spaces and online spaces, with respect to this module’s emphases on making our spaces universally accessible, inclusive, and welcoming to all populations. Do any issues matter more or less for physical spaces, as compared with online spaces? Why or why not?
Module 16: Copyright 2025 by Compass Communications LLC. Reviewed December 2025.