South East Consortium for Special Education
3434 Marten Ave.
San Jose, CA 95148
Phone: 408.223.3771 / Fax: 408.532.9311
August 2015
Dear Director of Special Education,
As per your input, the SELPA have established a contract with The Speech Pathology Group (SPG) to provide Augmentative and Alternative Communication Assessments (AAC) for your district for the 2015-2016 school year.
To make a referral please send the following information to 925-945-1768, or scan and send to
The Speech Pathology Group Clinic Services, ATTN: Jenny Ogar
Completed SELPA Augmentative and Alternative Communication Assessments (AAC) form
Evaluation Reports (Psycho-Ed., Speech, OT, etc.) from the PAST TWO YEARS, and current/subsequent IEP including IEP meeting notes.
Signed and dated Assessment Plan for AAC Assessment
Please note that SPG will need these documents before they can contact students’ families for scheduling.
To schedule an IEP and confirm the assessor’s attendance after the assessment report is complete: Contact Jenny Ogar at or at 925-945-1474 x131
To withdraw or cancel a submitted referral: Please contact Jenny Ogar as well as the Speech Pathology Group as soon as possible. If the assessment is already in process, you will be billed a pro-rated amount
If you have any questions, please do not hesitate to contact the SE SELPA office
Regards,
Leo Mapagu
Director, South East Consortium
AUGMENTATIVE/ALTERNATIVE COMMUNICATION (AAC) ASSESSMENT
REFERRAL FORM
The Speech Pathology Group, Inc. is available to complete Augmentative/Alternative Communication (AAC) assessments for school district referrals. In order to efficiently facilitate the evaluation and conduct it in a comprehensive manner, we kindly ask that a district staff to complete the form. The Special Education Director must sign the document to indicate approval.
NAME OF SCHOOL DISTRICT: ______ DATE: ______
STUDENT NAME: ______DATE OF BIRTH: ______GRADE: ______
PARENT/GUARDIAN ______ PHONE:______
PARENT/GUARDIAN EMAIL ADDRESS:______
FORM COMPLETED BY: ______ TITLE______
Phone number: ( ) ______Email: ______
Best times to contact: ______
TEACHER NAME: ______CONTACT INFORMATION: ______
SCHOOL SLP NAME: ______CONTACT INFORMATION:______
CLASSROOM OBSERVATIONS:
Does school district authorize an on-site observation of the student Yes No
If Yes, contact person to arrange observation: ______
Phone/email of contact person: ______
COMMUNICATION CONCERNS:
The following areas of speech-language are of concern:
Articulation/speech intelligibility Oral-motor skills Feeding skills
Voice (volume, pitch, quality) Social-pragmatics
Vocabulary/semantics Grammar/syntax Communicative intent
COMMUNICATION METHOD:
What method of communication is the child currently using?
Verbal Speech Pictures/PECS
Gestures/Signs AAC Device/App - If so, device used______
No communication method identified at this time
IEP Goal(s) AAC needed to support ______
______
______
Assistive Technology currently used (i.e., wheelchair, switches, visual schedules, etc.)
______
PLEASE NOTE: As independent assessors, we may find areas of deficit/delay that do not meet eligibility criteria under Special Education codes. We reserve the right to inform parents/advocates of such areas as a result of our testing with the understanding that the information will be shared with the IEP team.
Please note the following documentation must be attached to begin the referral process:
Completed SELPA Augmentative and Alternative Communication Assessments (AAC) form
Evaluation Reports (Psycho-Ed., Speech, OT, etc.) from the PAST TWO YEARS, and current/subsequent IEP including IEP meeting notes.
Signed and dated Assessment Plan for AAC Assessment
______
Signature of Special Education Director District Director Printed Name
Please fax forms to: 925-945-1768, or scan and send to
The Speech Pathology Group Clinic Services
ATTN: Jenny Ogar
Alum Rock Union School District * Berryessa Union School District* East Side Union High School District* Evergreen School District*Franklin McKinley School District*Gilroy Unified School District*Milpitas Unified School District*Morgan Hill Unified School District*Mount Pleasant School District*Oak Grove School District* Orchard School District* Santa Clara County Office of Education