5
Augmentative Communication Referral
for
Consultation / Evaluation
Thank you for your support of patients with complex communication needs. In order to facilitate this process, we need you to take some time out to complete some intake paperwork (included in this packet). These are the general questions that we need to answer before we can come out:
· Why do you need the consultation?
· What do you already know?
· What have you already tried?
· Are the families/caregivers/therapists interested in doing their part to provide any AAC tools/strategies?
Please complete the following 2 forms:
1) Referral Letter (Pages 2-3)
2) AAC Communicator Referral Profile (Pages 4-8)
Email them to .
Thank you for taking the time to do this.
AAC Consultation/Evaluation Team
Augmentative/Alternative Communication (AAC) Referral
Name of referring therapist: ______SLP ___ OT ___ PT ___ABA ___
Initials of patient and Account #: ______
Date request completed: ______
Are you interested in having an augmentative communication (AAC) evaluation and or/consult for your patient . We have a therapist that will be happy to assist you. In order to make effective use of your/their time, we need you to provide additional information. Complete this form and email to . We will respond within a few days. Until we have more trained people, we would like to ask you to limit your referrals to only 2 at this time.
Please check the appropriate situation below:
___ I am the primary SLP for this patient. (If not, then indicate your position in PPHC).
Check one that best describes your situation:
___ I am looking for recommendations on AAC strategies/tools for an emerging communicator (individual that is not currently using pictures or other AAC tools).
___ I am looking for recommendations for an individual who is currently using some AAC tools/strategies but want to know the next step.
___ My patient already has an AAC device. (Name of device:______). I need help with ___ ideas for functional use ____ how to set up pages ____programming
____ I am looking for a recommendation for an AAC device.
____ I am looking for an AAC app to use on an iPad / Android tablet / PC tablet ( circle one)
____ The parents have requested a device. Do they have a specific one in mind? Circle: Yes/No.
If they do, please put in the name or "type" of device they want (i.e. eyegaze, iPad, etc.) or model of device (i.e. DynaVox, NovaChat, Unity , Tobii, AbleNet, etc. ) ______
Following are the pre-requisites for AAC evaluations/ consultations:
1) The patient needs to have a primary speech therapist assigned.
2) The family/caregivers are interested in using AAC strategies/tools. In order for us to be more effective, the home situation will need to use agree to USE the AAC strategies/tools in functional situations as appropriate.
3) You will need to fill out the AAC Communicator Profile. This will help the AAC consultant work more effectively and efficiently with the SLP, other therapists, and the family. You are asked to complete the RED portion as much as you can.
4). Please read and check that you/the family can agree to the following conditions:
___ The family / caregiver is interested in having some new AAC tool/strategies and understand that they will be asked to use them in functional situations at home as appropriate.
___ Consultations are currently available on Thursday (all day) and Friday mornings (as available). Other days are on a case by case basis. We hope that you can make accommodations in your schedule for the evaluation. We also ask that the family be flexible if they need to take the child out of school for this initial evaluation. You will be contacted with schedule options.
___ The speech therapist and primary family caregiver are requested to be part of the initial evaluation session if at all possible. Since PPHC cannot bill for 2 speech therapy sessions in one day, you will be paid as a "training" session in the amount of $25. In order to receive payment, you will need to complete a "Non-Billable Note Training" located under the Clinical Forms section of Devero.
____ A 2nd session or diagnostic therapy for a few sessions may be required. In most cases this will be using PRN visits - so you can carry on with your therapy visits / plans. Please make sure that you have some available for future visits in the current or upcoming rec-cert period.
____ Some AAC materials may need to be made by the primary therapist or the family as needed. Premade materials and templates can also be available as needed.
____ Funding options will vary with each situation and you may be asked to complete the necessary paperwork.
____ If you cannot meet any/all of these conditions, please explain or any other questions or concerns? (Please put on back)
Please NOTE: The AAC consultant will complete the Treatment Note for the session plus email you the summary of the session and Plan of Action. Be sure and fill out your paperwork NON_BILLABLE TRAINING NOTE (Under CLINICAL FORMS) in order to be paid the $25.
Thank you for your referral. We look forward in supporting you to find effective AAC communication solutions for your patient. You will be contacted within a few days.
Regards,
AAC Communicator Profile:
Abilities, Functions, and AAC Tools/Strategies
NOTE: YOU ONLY NEED TO COMPLETE THE PORTIONS IN RED:
I. Patient initials + Account #: SLP Name:
Phone no:
Date form completed: email:
Current recert period dates: Days patient available ___ All day ___Thurs. __Fri. AM
Funding: ___ Medicaid ___other insurance ___CES Waiver __Family Support __PrivatePay ___ Other:______
AAC CONSULTANT WILL COMPLETE portions in BLACK:
Devero access requested: ___yes ___no Other PPHC Therapist: ___OT___ PT___ABA
Birthdate/Age:
Address:
Diagnosis (es): Communication diagnosis:
School contact: SLP/Teacher/AT team Contact info: email /phone
Family Contact name:
Contact name: ______Circle preferred contact mode:
cell / home phone ______text ______email______
Vision concerns / modifications: (Circle if applies): glasses, blind , cortical blindness, visual neglect, other:
Hearing concerns modifications: (Circle if applies): mild/moderate/ severe loss, hearing aid - in ear / external/cochlear implant, other:
Physical limitations/modifications: (Circle what applies): ambulatory (w/o assist; w/ assist / walker) - uses wheelchair - is reclined much of time in bed, etc. - upper body limitations; arms / hands / tremors / crossing mid-line - head control; hold up/move side to side, (more on next page under ACCESS)
Other concerns: fixates on activity/situations/people, feeding challenges (G-tube, limit liquids, modified diet - how? ), easily distracted, does not sit still, behavior, others:
II. Access options to AAC: all that applies; if you don't know, then leave blank .
not sure - need assistance with access
direct select - can touch symbol directly ( with finger, hand) ___ limited ___ stylus ___ keyguard (# of keys ___)
___ uses other body part
head pointing option (if can't do direct select) ___ has good head control
eye gaze option (if can't do direct select) ___can hold head up or
___ can be positioned to hold head up
scanning (if can't do direct select) ___ can scan with switch
___ use single switch ___ use 2 switches; ___ name of switch(es)
___ location of switch (by hand, head, elbow, leg, other ______)
___type of scanning ___ auditory scanning ___visual scanning ___linear ___ row ___ group
III. Current Forms of Communication (non AAC) : Put if using.
Body language: ___facial expressions ___body language ___look at ___reach for ___point at ___ take you to ___ gestures
Signs (Circle # of spontaneous signs 1-10, 10-25, 25-50, 50+) Examples:______
Verbal speech
·___ utterances / generalized sounds
·___ single words # of spontaneous words (Circle # of words 1 - 5, 5-10, 10-25, 25-50, 50-100, 100+ )
Examples if 10 or less words used: ______
·___phrases ____routine sentences ____unique sentences ___syntax good ___ use of morphology forms
· ___% intelligibility ____% familiar ___% unfamiliar
· Example of phrase and/or sentence. ______
______Echolalic (is it functional?) ____ ongoing speech but not sure what they are saying
Symbols used: ___ objects___ photos ____Google, etc. ___ icons (i.e. Boardmaker, etc.)___ words ___alphabet for spelling (ABC / QWERTY layout)
If using pictures on ANY AAC system (LOW, LITE, or HIGH TECH) please complete this information:
· How many pictures per page ___ (unless it is single pictures)
· How many pages? ____
· Pages sorted by ___categories (i.e. food, activity, etc). or by ___situation (i.e. lunch, playground, schedule, etc.)
IV. Low & Lite Tech AAC Tools. Put if currently using.
If using pictures - which low-tech tool? : ___ simply hold up pictures ____PECS ___key ring ___communication board(s) ___ communication book ___laptray ___ eye gaze board
Partner assisted scanning ( ___don't know what this is ____ just starting to use
___ is doing successfully)
How do they indicate when to stop scanning? ___ body language ___verbalization ___single message communicator
Single message communicator ___Big Mac/Step-by-Step; ___not sure what this is ; ___other (name/manufacturer):
Digitized device; simpler devices recorded with a voice: (Circle name: GoTalk, 7 Level Communicator, QuickTalker, other)
V. High -Tech Communication Device(s) with voice output.
Put if currently using.
___ iPad /tablet ___Family has ___ SLP has: AAC app used and name(s) below: ______
___other uses for personal iPad (circle): videos, movies, cause/effect or interactive games; name below)
AAC Device (also called SGD or Speech Generating Device):
Name: ______(own or loaner)
___ Currently using or ____ Previously used; why not using now?
When provided ______(approximate date) Serial number:______
How do they use the iPad or SGD? ___use preprogrammed phrases ___use single words
___ can create routine sentences ___create own sentences
___ ask questions ___ telegraphic (get message across?) ___correct syntax ___correct morphology
Example of phrases / sentence they use: ______
SLP have iPad? Any AAC apps on it? ______
Behaviors : ( cry, scream, hit self / others, scratch, push, pull, throw, kick, other:______)
Circle what you think they want/have a need for: don't know, attention, something/someone, don't want something/someone, pain, physical needs (hunger, thirst, pain, positioning, toileting,) , other:
VI. Functions of Communication:
Please complete which communication functions are observed/reported by circling:
1= not effective 2= effective sometimes 3= effective most of the time .
There is an OPTIONAL place for the family to do the same.
Info for AAC Consultant only: How: (Eyes, Gesture, Sign, Verbal, Pics, LowTech, LiteTech, HiTech, iPad)
SLP Family (optional)
___ Attend to environment 1 2 3 1 2 3
___ Attend to others 1 2 3 1 2 3
___Desire to interact with others 1 2 3 1 2 3
___ Follow simple directions 1 2 3 1 2 3
___ Request attention 1 2 3 1 2 3
___ Can wait appropriately 1 2 3 1 2 3
___ Express wants / needs for preferred activities ( ** NOTE**: list top 3 that can be done at consultation LISTED HERE and please have those available. )
1 2 3 1 2 3
ACTIVITIES TO DO: 1)
2)
3)
___ Express basic wants/needs:(attention, hunger, thirst, toileting, positioning, help, pain)
1 2 3 1 2 3
___ Protest appropriately 1 2 3 1 2 3
___Make request choices 1 2 3 1 2 3
___Indicate to stop / continue an activity/situation (MORE/ALL DONE etc.)
1 2 3 1 2 3
___Request help/assistance 1 2 3 1 2 3
___ Greetings 1 2 3 1 2 3
___ Answer YES/NO questions (preferences, basic, complex)(R)
1 2 3 1 2 3
___ Express how they feel (beyond body language/vocalizations)
1 2 3 1 2 3
* * * * * * * NOTE: STOP HERE IF YOU HAVE 8 (eight) or MORE 1's circled. * * *
Info for AAC Consultant only: How: (Eyes, Gesture, Sign, Verbal, Pics, LowTech, LiteTech, HiTech, iPad)
SLP Family (optional)
___ Identify pictures/objects/people (nouns) (R) 1 2 3
1 2 3
____Name objects, pictures, people (nouns)
1 2 3 1 2 3
___ Make comments (example like / don't like)
1 2 3 1 2 3
___ Answer questions (simple, complex)
1 2 3 1 2 3
___ Describe (adjectives) 1 2 3 1 2 3
___ Ask questions (simple, complex)
1 2 3 1 2 3
___ Direct actions of others 1 2 3 1 2 3
___ Relate personal experiences 1 2 3 1 2 3
___Give personal information 1 2 3 1 2 3
___ Express sense of humor 1 2 3 1 2 3
___ Repair communication breakdown
1 2 3 1 2 3
___ Express novel thoughts and idea:
1 2 3 1 2 3
Observations / Strategies: Put if any apply.
___ Responds to voice output ( ___YES ___ NOT REALLY ___ DON'T KNOW )
___ Interested in iPad for communication ( ___YES ___DON'T KNOW ___NO ___PREFERS OTHER ACTIVITIES ONLY; NOT GOOD FOR AAC USAGE)
___ Patient has some additional equipment available not already listed: ( device, single message communicator, switches, mounts, adapted toys, etc. ): Please list: ______
___ Other helpful information: (continue on back as needed or email info with this form)
Debra McBride Ligon 8.16