Appendix A Referral FormPage 1

Appendix A AAC:IR Form

Somerset Communication Aid Provision Partnership

Referral Form for an

Alternative and Augmentative Communication Aid Assessment

Please make sure that as the referring agent you are familiar with the terms and conditions of the AAC Policy before submitting a referral. This includes the minimum requirements for a referral.

Please submit this form electronically as well as in hard copy format

This referral should be made by the pupil’s speech and language therapist in conjunction with the class teacher.

Name of pupil
DoB:
School:
Home Address
Home phone number
GP Name and Surgery
Name of referral agent(s):
Speech and language therapist:
Teacher:
Address and contact details of Speech and Language therapist: / E-mail:Tel:
Date of referral:
Professionals involved
e.g. Physio, OT etc
Please add as necessary- / Name:
Contact address:
Phone/e mail
Name:
Contact Address:
Phone/E mail
School Action Plus category (if appropriate): / Category:
Please attach copy of the last annual review or SAP Review (if available)
Description and level of child’s communication development:
(and communication diagnosis if possible)
Please attach a copy of latest SLT report if available
Details of low tech system in place eg Communication book, signing, a message aid eg Big Mac:
Please attach an example of a communication book page and detail where, when and how this is used.
Please describe examples of-
  • Ability to initiate communication-
  • An understanding that communication is a two way process
  • A basic level of language comprehension 2 years or (P5)

Please state how long the system has been in place:
Which aid/ communication tool is used when and where and how often
Please give brief details of why an assessment for an aid has been requested.
If the child has already had an assessment for an aid please attach report.
Give a brief description of when and how the child uses computer equipment including the software used:
Please attach at least one example of a piece of work the child has produced using the computer and explanations as to how this piece of work was arrived at, e.g. how much guidance and help was given, what access method was used e.g. mouse, roller ball, switches etc. Video clips and photos are very helpful.
Are there any fine motor difficulties identified? Has the child ever seen an Occupational Therapist?
Describe the access devices used with the computer eg switch, joystick mouse etc, if applicable:
Please describe the child’s literacy level, if age appropriate.
How is the child supported in school?
Amount of LSA support:
Names of LSAs: / Name:
Name:
Name of contact person at school e.g. SENCo
E-mail etc
Signature of parent
I agree with this application and will support the use of the aid and attend the training required.
I agree for photos/video clips to be sent with the referral. / Signed
date:
Signature of Headteacher
I support this application and if an aid is loaned, will place it on the school’s inventory for insurance.
I understand that some time will need to be spent for training and planning by staff. / date:
Signature of referral agent
I agree to take over the clinical responsibility after 6-12 months and to follow up the aims and objectives. / date:
Attachments:
The following must be included with the referral / Copy of most recent SLT report 
Copy of most recent Annual Review/ SAP Review 
Any other reports e.g. OT,
other AAC Assessment Reports 
Photocopy sample and/or a photo
of child’s low tech system 
Example of computer work and explanation of how this work was produced 
Desirable but not essential / A short piece of video or photographs of the child communicating or using IT can be enormously helpful for the panel to make a decision about the appropriateness of the referral. Any clips will be kept securely and destroyed once the decision has been made.

This form needs to be completed and sent as an attachment to-

Kate Holloway using the following e-mail and

Annette Davies using the following e-mail

And a hard copy with attached documents and signed form- posted to:

Kate Holloway PIMS Team, The Holway Centre, Byron Road, TauntonTA1 2JD

Updated 2010