Community O.T. Other: Has the referring SLP attended an ACS Information Session?
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1 AUGMENTATIVE COMMUNICATION SERVICES APPLICATION - Face to Face Section 1 To be completed by Speech-Language Pathologist Has the client been referred to ACS in the past? If yes, please use the ACS Re-Referral Form instead. Date of Referral: Client s Name: Name of Client s School: Client s Health Card No.: Date of Birth: SLP Name: Are you an Individual Authorizer? SLP Address: Has the client received a prescription of face to face communication equipment from an Individual Authorizer? Briefly describe your expectations of this referral: Has this referral been discussed with any of the following? School Team Community SLP Community O.T. Other: Has the referring SLP attended an ACS Information Session? COMMUNICATION SKILLS: (as observed by SLP) Environment: (e.g. School, Therapy sessions) Does the individual: Recognize names of familiar people? Recognize names of favourite things? Respond to his/her name? Follow simple one step commands? Follow two step commands? Use pictures to help him/her understand routines, expectations or instructions? Does the individual attempt to communicate? Does the individual initiate communication or try to gain attention? If yes, how? Does the individual respond to other people s communication? Does the individual: take turns make requests make choices express feelings
2 ACS APPLICATION - Face to Face Page 2 of 6 Describe how the individual indicates: Yes: No: Is it reliable? Yes No Is it reliable? Yes No PRESENT MEANS OF COMMUNICATION (as observed by SLP) (Check all that apply) changes in breathing patterns eye movement single words (how many) body position changes vocalizations (sounds) two word phrases eye pointing vowel sounds three word phrases facial expressions pointing three or more word phrases gestures signing Does the client understand: (a) cause and effect (b) turn taking (c) waiting for a turn Can the client read? If yes, at what level? letter recognition single words environmental print (e.g. McDonalds, brand names) phrases, more Can the client independently generate some written text? (e.g., sound out and spell simple words or short sentences) AUGMENTATIVE COMMUNICATION (as observed by SLP) Environment: (e.g. School, Therapy Session) Has the client used or is currently using an augmentative communication system or device? Describe fully. Name of device: How many vocabulary items on device? What is the size of the pictures/symbols/letters the client is using? (Attach a copy of board/display) How does the client access their current system? (i.e., by pointing, with a switch, joystick, etc.) How long has the system been in use? Purchased system? Have you leased a system in the past? Describe the successes and difficulties in using the current system: Completed by: Signature Date
3 ACS APPLICATION - Face to Face Page 3 of 6 Date of Completion: AUGMENTATIVE COMMUNICATION SERVICES Application-Face to Face Section 2 To be completed by Parent Client s Name: Male Female Date of Birth: Client s Health Card No.: Red/White Green Is client receiving ACSD benefits? Diagnosis: Address: The client lives with: Please describe any custody arrangements: Who is the legal guardian/decision maker? Mother Name: Address: Name: Address Father Telephone No.: Home: Telephone No.: Home: Work: Work: Cell: Cell: Is English a second language for the client/caregiver? Language spoken in the home: Is an interpreter needed for appointments? Briefly describe your expectations of this referral: Have you attended an A.C.S. Information Session? Date: Have you discussed the referral with any of the following? Therapy Team OT School Team Other: CLIENT ABILITIES (as observed by family) Can the client: Point with finger Grasp objects Release objects Does the client: Walk independently Use walking aids Describe: (e.g. cane, walker) Use a manual wheelchair Use a power wheelchair
4 ACS APPLICATION - Face to Face Page 4 of 6 Is vision a concern? Describe difficulties: Are glasses worn? If yes, has the client been seen by: optometrist / ophthalmologist Low Vision Clinic at University of Waterloo Is hearing a concern? Describe difficulties: Are hearing aids worn? Which ear? Left Right RECREATION List any recreation/leisure activities, programs or therapies in which the client is involved on a regular basis (e.g., Scouts, Music Therapy, Special Olympics) COMMUNICATION SKILLS (as observed by family) Does the individual: Recognize names of familiar people? Recognize names of favourite things? Respond to his/her name? Follow simple one step commands? Follow two step commands? Use pictures to help him/her understand routines, expectations or instructions? Does the individual attempt to communicate? Does the individual initiate communication or try to gain attention? If yes, how? Does the individual respond to other people s communication? Does the individual: take turns make requests make choices express feelings Describe how the individual indicates: Yes: No: Is it reliable? Yes No Is it reliable? Yes No PRESENT MEANS OF COMMUNICATION (as observed by family) (Check all that apply) changes in breathing patterns eye movement single words (how many) body position changes vocalizations (sounds) two word phrases eye pointing vowel sounds three word phrases facial expressions pointing three or more word phrases gestures signing Does the client understand: (a) cause and effect (b) turntaking (c) waiting for a turn Can the client read? If yes, at what level? letter recognition single words environmental print (e.g. McDonalds, brand names) phrases, more
5 ACS APPLICATION - Face to Face Page 5 of 6 Can the client independently generate some written text? (e.g., sound out and spell simple words or short sentences) AUGMENTATIVE COMMUNICATION (as observed by family) Has the client used or is currently using an augmentative communication system or device? Describe fully. Name of device: How many vocabulary items on device? What is the size of the pictures/symbols/letters the client is using? (Attach a copy of board/display) How does the client access their current system? (i.e., by pointing, with a switch, joystick, etc.) How long has the system been in use? Purchased system? Have you leased a system in the past? Describe the successes and difficulties in using the current system: Please list any community supports that this person is involved with (e.g. school, therapists, social services) Completed by: Signature Relationship to Client Date FAMILY / GUARDIAN ACKNOWLEDGEMENT (this must be completed before referral is accepted) I am aware of and in agreement with the information provided in this questionnaire. I consent to my child being referred to KidsAbility Augmentative Communication Services. Signature Relationship to Client Date Please be sure to complete Page 6 FACILITATOR INFORMATION FOR CLIENT
6 ACS APPLICATION - Face to Face Page 6 of 6 FACILITATOR INFORMATION FOR CLIENT Name of Client: A Facilitator is usually a parent, guardian or designated caregiver who has frequent contact with the client and is able to commit to: (a) attending the interview and assessment sessions at KidsAbility s Augmentative Communication Services (b) providing regular client-training sessions until the client is competent in the use of his/her system(s) (c) teaching others about the client s communication system(s) (d) updating and maintaining the client s communication system(s), and (e) serving as a liaison between the client and KidsAbility s Augmentative Communication Services, for the scheduling of appointments, troubleshooting of equipment and discussion of issues regarding leasing and use of device. Who is the main person who will function as the facilitator? Name: Relationship to Client: Agency: Telephone: Address: Fax: Have you worked with individuals who use augmentative communication systems before? If yes, please describe your experience: Do you have any computer experience? If yes, please describe your experience: How much time do you spend with the client? In an average week: hours Please describe the activities in which you are involved with the client: ATTENTION: The information communicated between KidsAbility s Augmentative Communication Service and facilitators is confidential and legally privileged. KidsAbility s Augmentative Communication Service will not disclose or discuss information relating to the client with anyone other than identified facilitators and legal guardians. FACILITATOR COMMITMENT I agree to act as a facilitator for the client described above, and I accept the responsibilities as outlined. Signature (Facilitator) Date
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