<p> 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</p><p>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</p><p>Reason for referral. For what specific purposes will the client use a communication aid and what impact will that have? </p><p>Where will the client need to communicate?</p><p>Why has the referral been made at this time?</p><p>Has the client had an AAC assessment before? Yes ☐ No ☐ If yes, please provide details, including copies of any reports.</p><p>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)</p><p>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.</p><p>COMPREHENSION</p><p>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 </p><p>EXPRESSION</p><p>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</p><p>Is the clients medical condition changing quickly? No ☐ </p><p>If Yes describe:</p><p>Does the client have any hearing loss? No ☐ </p><p>If Yes describe:</p><p>Does the client have visual problems? No ☐ If Yes describe:</p><p>Does the client have any memory difficulties? No ☐ If Yes describe: Does the client have reduced concentration/ attention No ☐ span? If Yes describe:</p><p>Please describe the client’s physical ability:</p><p>Ambulant ☐ (Aid Needed? Type?)</p><p>Power wheelchair ☐ (Type?)</p><p>Manual Wheelchair ☐ (Type?)</p><p>Sitting ability </p><p>Hand function </p><p>Head Control </p><p>Best movement Does the client have an environmental control system? No ☐ </p><p>If Yes what type?</p><p>Does the client know how to use a computer? No ☐ </p><p>CONTACTS Who does the client live with? Relationship: Contact details: Mobile no:</p><p>Email:</p><p>Contact Details for college/day centre</p><p>Address:</p><p>Postcode: Who will attend the appointment? Please include addresses if not given above. Name Address if not already given</p><p>Days SLT(referrer) available to attend appointment Tues ☐ Wed ☐ Thurs ☐ Fri ☐ </p><p>Email address for SLT/referrer :</p><p>Contact details for next of kin:</p><p>Name Relationship</p><p>Tel no: Mobile no:</p><p>Address:</p><p>Postcode: Email:</p><p>Signed: Date:</p><p>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</p>