Referral Form
This referral form should be completed for children and young people who will meet the criteria for a specialist Augmentative and Alternative Communication (AAC) service intervention.
An individual who would access a specialist AAC service would:
· Have a severe or complex communication difficulty associated with a range of physical, cognitive, learning or sensory deficits.
· Have a clear discrepancy between their level of understanding and ability to speak.
· Be able to understand the purpose of a communication aid.
· Have developed beyond cause and effect understanding.
And may:
· Have experience of using a low tech AAC device which is insufficient to enable them to realise their communicative potential.
The Kent and Medway CAT Service is jointly commissioned to support children and young people with SEN who have complex written communication difficulties. For this reason our criteria can also include children and young people who:
· Have complex physical difficulties which mean standard methods of accessing computers are not effective and appropriate and require a specialist approach.
· Require advice, for example regarding their progression in Assistive Technology (AT) use where appropriate curriculum software and alternative computer access devices have been trialled and evaluated.
· Require involvement to introduce technologies associated with alternative means of recording.
Referrals will be accepted from health, education and social care professionals working in local teams. The forms are of most use when completed by the team around the child or young person and their family.
Please keep information concise, key points are sufficient and attach additional pages where necessary.
This form should be completed electronically, if you require this form in alternative format or for assistance, please contact us.
Section 1:
1.1 Parental Responsibility, Consent and Mental Capacity:
Parental Responsibility:Please give details of all people with legal parental responsibility and ensure their contact information has been provided in section 2.4
Name: Relationship:
Name: Relationship:
Parental responsibility may be shared between a number of people beyond the child or young person’s natural parents; such as step parent, social worker or legal guardian. Please give details of any additional person with legal parental responsibility:
Name: Relationship:
Parental Responsibility (continued):
The Kent and Medway CAT Service includes professionals from a number of different organisations. In order to work together effectively, we need to collect and share information. We will all ensure that your information is processed fairly and lawfully in line with the Data Protection Act 1998.
· I have read this completed referral form and agree to the sharing of information between all practitioners and agencies in relation to all aspects of this process.
· I understand that this referral is the first stage in the application process for support from the Kent and Medway CAT Service. The submission of this form does not guarantee that support will be provided.
Signed: Print: Date:
Head Teacher Consent:
If the Kent and Medway CAT service provides support, then I understand that the school will need to provide the child or young person with equipment and ongoing human resources. There will need to be a plan for this specialist intervention within the individual’s provision plan. For example, teaching assistant time or technical support.
I understand that this will need to include a minimum of an individual education programme (or relevant individual targets) and should include one or more of the following:
· Use of specialised hardware and software.
· Keyboarding skills.
· Highly differentiated Literacy and Numeracy programmes at an appropriate developmental level.
· Personal care and independence skills.
· Highly differentiated Speaking and Listening skills programme.
· Learning environments where individual communication modes (for example PECS, signing, symbols, PODD and so on) are actively supported and developed.
· Support available to implement individual therapy programme(s) to address language skills as advised by therapists.
· CPD arrangements for training in AAC and AT systems.
Signed: Print: Date:
Please note: In order to process the referral, we must have consent from parents (or legal guardian) and the Head Teacher from the child or young person’s educational setting.
Mental Capacity (for young people over the age of 16 years old):Please demonstrate that under the Mental Capacity Act (MCA) you are making this referral in the best interests of the child or young person.
Has the child or young person consented to this referral?
☐ Yes ☐ No
If no, please attach a copy of the completed MCA assessment and state the reasons why this referral is in the child or young person’s best interests.
Section 2:
2.1 The Child or Young Person:
Surname: / Date of Birth:First name: / Age: years / months
NHS No: / KCC UPN: / School Year:
2.2 Parent or Guardian:
Parent/Guardian Name 1: / Parent/Guardian Name 2:Home Address: / Home Address:
Home Postcode: / Home Postcode:
Home Phone: / Home Phone:
Mobile Phone: / Mobile Phone:
Name of referrer: / Role:
Email: / Phone:
Address:
Signature: / Date:
2.3 Referrer:
2.4 Other Person(s) completing this request form, including the contact details of anyone listed in section 1.1:
Name / Role / Phone number / Email / Base2.5 School Information:
School: / School Key Contact:School Address:
School Postcode: / School Phone:
Section 3:
3.1 What do parents or carers expect to see happen as a result of this referral?
Is the child or young person educated at: / Type of School:☐ / School / ☐ / Pre-School / ☐ / Primary
☐ / Home / ☐ / Mainstream / ☐ / Secondary
☐ / Special School / ☐ / Further Education
3.2 What tasks does the school expect this child or young person to be able to do using AAC and AT that is currently difficult for them to achieve?
3.3 What tells you that the child or young person is ready to benefit from AAC or AT?
Please include their views if they have means to show what they want to change3.4 Please summarise the current level of involvement of support services:
Person 1 / Person 2 / Person 3 / Person 4 / Person 5Name of person and support service?
What support are you currently providing?
What is the focus of this intervention?
What is the frequency of involvement planned for the next 12 months?
Is a recent report or programme of intervention enclosed with the referral? / Person 1 / Person 2 / Person 3 / Person 4 / Person 5
YesNo / YesNo / YesNo / YesNo / YesNo
Has this person contributed to sections of this referral information? / YesNo / YesNo / YesNo / YesNo / YesNo
The purpose of attaching recent reports is to enable us to make an informed decision about the relevance of our service for this child or young person.
Section 4:
4.1 In this section, please tick all that apply in terms of the child or young person’s disability or limiting condition (including any mobility issues):
☐ / Cerebral Palsy / ☐ / Dyslexia☐ / Hemiplegia / ☐ / Degenerative condition
☐ / Learning difficulties / ☐ / Hearing Impairment
☐ / Acquired Brain Injury / ☐ / Visual Impairment
☐ / Emotional/behavioural difficulties / ☐ / Orthopaedic Impairment (Specify below)
☐ / Significant developmental delay / ☐ / Verbal Dyspraxia
☐ / Epilepsy / ☐ / Autistic Spectrum Disorder
☐ / Dyspraxia / ☐ / Specific Language Impairment (SLI)
☐ / Neurological disorder / ☐ / Speech and language difficulties
☐ / Sensory processing disorder / ☐ / Other
Any other specific diagnosis or additional comments:
4.2 Has the child or young person previously had a consultation with the Kent and Medway CAT service? If so, please evaluate the results of the recommended actions. If any recommended actions have not have not been carried out, please explain why.
4.3 In this section, please give details of any fine motor difficulties that the child or young person experiences. Please note the term ‘fine motor’ refers to the co-ordination of the smaller movements of the hands and fingers. Please comment on how the child or young person uses both arms and hands to perform everyday activities. Please indicate if and how their fine motor ability limits or impacts on their daily function.
For example, please describe how they hold and use writing tools, including how much physical effort is required. Please include information from an Occupational Therapist, especially regarding handwriting (including any timed handwriting assessments) and keyboard skills, if available.4.4 In this section, please tick all that apply in terms of gross motor difficulties that the child or young person experiences. Please note the term ‘gross motor’ refers to the co-ordination of large muscle groups and whole body movements, including movement and control of the head, legs and arms.
☐ / Limitations in range of movement (RoM)☐ / Unintegrated reflexes or abnormal muscle tone
☐ / Difficulty with accuracy of movement
☐ / Do they use mobility aids?
4.5 In this section, please give details of any sensory difficulties that the child or young person experiences. Please note the term ‘sensory’ refers to hearing, visual abilities and sensory processing needs. Does the pupil have any known sensory processing difficulties?
If yes, please explain how this impacts on their daily function and engagement, and provide information about any behavioural strategies used.If the child or young person is operating at ‘P’ levels or if there is evidence of significant delay in areas of Literacy, Numeracy, Language Comprehension and Expressive Language; please complete all sections of the profiles in sections 5, 6 and 7. If the child or young person is operating at ‘NC’ levels, please complete sections 6 and 7 only.
Section 5:
5.1 Numeracy (Please tick all that apply):
☐ / Engages in joint attention with adult(for example, number songs, stories, games) / ☐ / Can indicate ‘one’ or ‘two’
☐ / Shows an interest in number activities with
adults / ☐ / Joins in rote counting to 5
☐ / Shows awareness of number activities and
counting rhymes and songs / ☐ / Makes sets of up to 3
☐ / Follows a sequence of pictures or numbers / ☐ / Joins in rote counting to 10
☐ / Joins in with familiar number rhymes, songs
and games / ☐ / Recognises numerals from 1 to 5
☐ / Shows awareness of contrasting quantities
(for example, ‘one’ and ‘lots’) / ☐ / Joins in rote counting beyond 10
☐ / Understands one-one correspondence
(for example, matching cups to saucers) / ☐ / Continues to rote count onwards from a given small number
☐ / Demonstrates an understanding of ‘more’
(for example, more cups are needed) / ☐ / Recognises numerals from 1 to 9 and relates them to sets of objects
☐ / Demonstrates an understanding of ‘less’
(for example, which bottle has less water) / ☐ / Understands ordinal numbers (first,
second, third)
☐ / Picks out described shapes from a collection / ☐ / Estimates a small number up to 10
☐ / Recognises differences in quantity
(for example, which group has more or less) / ☐ / In practical situations, can respond to ‘add one’ or ‘take away one’
Please summarise how the child or young person demonstrates the skills listed in Section 5.1. For example, this could be by verbalising, writing, typing, pointing to flash cards, eye pointing using an E-tran frame, using a switch to scan and select.
If the child or young person is making a selection, for example from cards on an E-tran frame, please state how many choices are presented and how much support is given. For example they can identify which number comes ‘next’ in a given sequence by eye-pointing to the correct number from a choice of 4.Please summarise how the child or young person joins in with number rhymes and so on. For example, this could be verbally, signing, using gestures.
5.2 Literacy (Please tick all that apply):
☐ / Engages in joint attention with adult(for example, songs, stories, games) / ☐ / Writes (or types) emergently
☐ / Shows an interest in books and stories
with adults / ☐ / Can trace, overwrite, copy or replicate
shapes and straight line patterns
☐ / Understands how books work
(for example, can hold book the right way up) / ☐ / Produces their name in letters by copying
☐ / Shows an interest in looking at books
independently / ☐ / Copy letter forms to create labels or
captions and so on
☐ / Associates pictures with spoken words
when being read to / ☐ / When asked to spell a word, gets first
phoneme correct
☐ / Realises text conveys meaning / ☐ / When asked to spell a word, gets first
and last phoneme correct
☐ / Recognises connection between spoken
words and specific text when read to / ☐ / Makes phonetically plausible attempts at
spelling words
☐ / Recognises environmental print, / ☐ / Can spell words with some accuracy
☐ / Matches letters and short words / ☐ / Can produce single key words (for example, their name).
☐ / Predicts elements of a narrative (for example, what comes next) / ☐ / Can produce other single words
☐ / Understands conventions of reading (for example, following text from left to right). / ☐ / Groups letters and leaves spaces between them as though writing words
☐ / Applies phonic rules when attempting to decode words / ☐ / Forms short phrases
☐ / Blends sounds to make words / ☐ / Can produce sentences
☐ / Reads a number of familiar words or symbols / ☐ / Recognises at least half the letters of the alphabet by shape, name or sound
Please summarise how the child or young person demonstrates the skills listed in Section 5.2. For example, this could be by writing, typing, pointing to flash cards, eye pointing on an E-tran frame, using a switch to scan and select.
If the child or young person is making a selection, for example from letters on an alphabet board, please state how many choices are presented and how much support is given. For example, they can spell a word by pointing to each letter, from a choice of 8.
Section 6: