At Arena Evaluation Referral Information

AT ARENA EVALUATION – REFERRAL INFORMATION

Client Name: Guardian/Parent(s): ______Client’s House Manager (if applicable): Ph: ______PT (if applicable): Client’s Home Ph: ______Ph: Client DOB: ______OT (if applicable): Person making Referral: ______Ph: Date of Referral: ______SLP (if applicable): Case Manager: ______Ph: Agency: ______The need for this AT Arena Eval. was Ph: discussed with the ISP team and the team ______(including therapists if applicable) is in Fax: agreement that this Evaluation is ______recommended. Comments:

What is the client’s diagnosis? What are the person’s primary functional deficits related to this evaluation? Please check all that apply. Please comment in detail on areas checked and other functional challenges. Uses a wheelchair Uses a walker Is non-verbal Hard to understand Visually-impaired Hearing- Impaired Has poor motor-skills Can’t follow directions Has behavioral/emotional problems Other Comments:

What are the client’s main ISP Visions/Anticipated Outcomes?

What are the client’s main areas of interest? What activities does the client enjoy that may be helpful for this evaluation?

What AT Devices or adaptive equipment does the client currently use? Please comment on the effectiveness of these interventions.

Are there any specific AT Devices that the client has recently tried? Please comment on the effectiveness of these interventions. What are the team’s main objectives for this AT Arena Evaluation? (check all that apply) Explore options for augmentative communication devices. Explore options for low-tech communication systems. Explore options to help with cueing systems during functional activities, (i.e. memory, schedule, etc.) Explore options for AT for self-care or home living activities. Look at ways to access items in the environment like: TV, music, appliances, etc. Explore what types of switches might work best for the individual to access communication, leisure items, household items, computer use, etc. To help the individual access a computer for (circle those that apply): work, volunteering, leisure interests, communication, internet access, functional reading, other. (Note: Computer Access Evaluation is currently a limited program and does not cover all areas. You will be notified of evaluation resources related to this individual as well as technical assistance and referral in this area as appropriate.) To help the individual be positioned more effectively for activities. To look at mounting solutions on the person’s wheelchair for AT access. To explore power mobility options. To help the person integrate AT systems. IE: controlling a wheelchair, environmental control devices, communication devices so that systems work together effectively for the client. Other (please explain below).

Please comment on the above objectives in more detail.

SCHEDULING INFORMATION: The AT Team invites the person to be evaluated and all interested members of their IDT team to attend the evaluation. Normally the client, a caregiver, a parent, and therapist(s) attend the evaluation. Often the Case Manager attends as well. The AT Team identifies two or three open dates/times for the evaluation and holds these dates until the evaluation is scheduled with the individual and their team. I think it would be easier for me to schedule the evaluation. Please contact me with the AT Teams open dates.

I would like the AT Team to schedule the evaluation.

If you would like the AT Team to schedule the evaluation, please note who you would like us to contact and give contact information if different or additional to that given at the beginning of this form. We need an e-mail address or a postal address for each individual you would like us to invite to the evaluation.

NAME CONTACT INFORMATION

Thank you for your time in completing the above referral information. The AT Arena Evaluations take place at the Los Lunas Community Program building in Los Lunas. Directions will be forwarded if needed when a date is scheduled. We are looking forward to seeing you at the evaluation.

Please return this form along with relevant ISP pages (Cover sheet, medical information, Visions/Anticipated Outcomes, and Recent Therapy Reports) to:

Therapy Services Coordinator [email protected] Ph: 841-2913 Fax: 841-2987 Clinical Service Bureau 5301 Central NM; Suite 203 Albuquerque, NM 87108

Or to your AT Team contact person:

Fran Dorman, PT, MHS Ph: 841-5224 [email protected] Julie Mehrl, MOT,OTR/L Ph: 841-5341 [email protected] Lourie Smith Pohl, Ed.S, CCC-SLP Ph: 841-5254 [email protected]

The Fax # for the Therapy Services Unit is #841-5316 Therapy Services Unit PO Box 1269 Los Lunas, NM 87031