Clinical Verbal

COMMUNICATION AID ASSESSMENT REFERRAL FORM Specialist Disability Service, Oxford Centre for Enablement, Windmill Road, Headington, Oxford, OX3 7HE T: 01865 737 445 | [email protected] Please fill in this form electronically clicking the boxes will mark them with an x PATIENT DETAILS

Full name: NHS No: Please to confirm that the Specialist Disability Service referral form has Yes ☐ been completed and returned with this form. REFERRAL DETAILS

Reason for referral. For what specific purposes will the client use a communication aid and what impact will that have?

Where will the client need to communicate?

Why has the referral been made at this time?

Has the client had an AAC assessment before? Yes ☐ No ☐ If yes, please provide details, including copies of any reports.

Describe how the client communicates at present (include full details of low-tech AAC used. If low tech has not been tried please contact the SLT on the above number before proceeding with the referral)

Yes ☐ No ☐ Does the client have a reliable yes/no response? Yes/No Please provide details of how client indicates yes/no Please choose from 1-7 on the following charts for each of skills A-H and mark with x.

COMPREHENSION

A B C Clinical – Functional (supported by social Clinical written verbal context) Able to follow 7 group ☐ Able to read short stories ☐ Follows “abstract” conversation ☐ conversation Able to follow 6 long complex ☐ Able to read newspaper articles ☐ Follows complex/ concrete conversation ☐ commands Able to follow Follows “everyday” conversations without short complex Able to read paragraphs for meaning 5 ☐ ☐ difficulty ☐ commands Able to follow 3 + Able to read sentences for meaning. Able to “get the gist” of conversation 4 word commands ☐ ☐ ☐ Able to follow 2 Responds appropriately to utterances of 2- Able to read short phrases for meaning 3 word commands ☐ ☐ 3 word level in a single interaction ☐ Follows only 1 Responds appropriately to single word Able to read single words for meaning 2 word commands ☐ ☐ utterances ☐ Unable to follow Unable to read single words for single word Unable to follow spoken output at all 1 ☐ meaning ☐ ☐ commands

EXPRESSION

D E F G H Functional verbal/ non Clinical Spelling Articulation Word finding verbal (inc. use of verbal AAC/gesture) Able to produce Able to use Showing full range of complex sentences/ No difficulties No difficulties pragmatic skills (no 7 connected ☐ ☐ ☐ ☐ ☐ paragraphs problems) speech Nearly all/all of Able to produce Able to retrieve Able to express needs, Able to convey output is simple words correctly wishes and desires to 6 ☐ short phrases ☐ intelligible to ☐ ☐ ☐ sentences over 75% of time. any audience listeners 75% + of output is intelligible/ acceptable, save Able to retrieve Able to engage in social Able to produce Able to spell specific words correctly 50- interaction with 5 short clauses ☐ single words ☐ parameters eg: ☐ ☐ ☐ 74% of time unfamiliar people articulatory postures or intonation Approx 50-74% of Able to produce Able to retrieve Able to engage in social Able to spell part output is 2 –3 word words correctly 25- interaction with familiar 4 ☐ of words ☐ intelligible to ☐ ☐ ☐ phrases 49% of time people listener Approx 25-49% of Able to retrieve Able to convey basic Able to produce output is words needs only (to (a) single word Unable to spell 3 ☐ ☐ intelligible to ☐ appropriately < ☐ familiar / (b) unfamiliar ☐ utterances listener. 25% of time people). Less than approx Maintains eye Able to verbalise 25% is intelligible contact/smiles in 2 Yes / No ☐ ☐ ☐ to listener. response Occasional word Unable to convey even 1 only is intelligible ☐ basic needs/poor eye ☐ to listener contact. MEDICAL INFORMATION

Is the clients medical condition changing quickly? No ☐

If Yes describe:

Does the client have any hearing loss? No ☐

If Yes describe:

Does the client have visual problems? No ☐ If Yes describe:

Does the client have any memory difficulties? No ☐ If Yes describe: Does the client have reduced concentration/ attention No ☐ span? If Yes describe:

Please describe the client’s physical ability:

Ambulant ☐ (Aid Needed? Type?)

Power wheelchair ☐ (Type?)

Manual Wheelchair ☐ (Type?)

Sitting ability

Hand function

Head Control

Best movement Does the client have an environmental control system? No ☐

If Yes what type?

Does the client know how to use a computer? No ☐

CONTACTS Who does the client live with? Relationship: Contact details: Mobile no:

Email:

Contact Details for college/day centre

Address:

Postcode: Who will attend the appointment? Please include addresses if not given above. Name Address if not already given

Days SLT(referrer) available to attend appointment Tues ☐ Wed ☐ Thurs ☐ Fri ☐

Email address for SLT/referrer :

Contact details for next of kin:

Name Relationship

Tel no: Mobile no:

Address:

Postcode: Email:

Signed: Date:

Name: Profession: Document name Co Issue Date/Author SA Reviewed 02/06/2017 Version 2.1 mm uni cati on Aid Ass ess me nt refe rral for m