Referral to NHS Specialised AAC Service
This form is to be completed for referrals to the NHS Specialised AAC Service.
ACE Centre has been contracted by NHS England to complete complex
communication assessments across 2 regions:
The North West
Thames Valley and Wessex
Please complete this referral form in as much detail as possible and return it by
one of the following means:
Email:
Fax:
Post:
smccormack@acecentre.org.uk
0161 358 0152
ACE Centre, Hollinwood Business Centre, Albert Street, Oldham
OL8 3QL
Once we have received your referral we will acknowledge this by email. Please
indicate the preferred name and email address for us to use:
Contact 1:
Contact 2:
Alternatively please provide a telephone number and postal address:
Section 1: Details of person being referred for an assessment
Title
Full Name
Date of Birth
Gender
First Language
Other Languages
NHS Number
Ethnicity
Home Address
Telephone Number
Mobile Number
Email Address
Preferred venue for assessment
If over 18 years of age, has the client
given consent for this referral?
Yes
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk
No
Section 2:
Details of parent/guardian/carer
We require consent to complete an assessment for all children and any adults
unable to express their own consent
Name of parent/guardian/carer
Relationship to person being
referred
Home Address
Telephone Number
Email address
Signature
Date
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk
Section 3:
Details of referrer
Name
Profession or relationship to
person being referred
Contact Address
Telephone Number
Email address
Signature
Date
Where did you hear about ACE
Centre?
e.g. Previously referred/internet/
word of mouth/mail shot / Other – (please specify)
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk
Section 4: Details of General Practitioner (GP)
GP (Name and Initial)
Surgery Address and Postcode
Telephone Number
Section 5: Details of School, College, Day Centre, Work Place
Name of School/College/Day
Centre/Work Place
Type of establishment
e.g. mainstream school, special
school, college, workplace etc.
Address
Telephone Number
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk
Section 6: Reason for Referral
Does the patient meet the criteria for
eligibility as defined within service
specification D01S/b?
Please provide a description of how the patient
meets each of the inclusion criteria
described in the service specification
What is the purpose of this referral?
e.g. To provide a temporary means of
expression
To identify an alternative to natural speech
To replace behaviours that challenge
To augment unintelligible speech
What are the patient’s expectations of this
assessment?
What are the current barriers to
communication competency?
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk
Section 7: Medical Information
Details of diagnosis or disability
Is the client’s medical condition
changing quickly?
Yes
No
Other relevant medical information
Section 8: Physical and Sensory Skills
Gross motor skills
(please detail movement of large muscle
groups and whole body movements
including movement of the head, legs and
arms)
Fine motor skills
(coordination of the smaller movements
of the hands and fingers)
Would a communication aid need to be
mounted?
Where does client spend most of their time
and require access to the device?
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk
Include details of wheelchair or seating
systems/ positioning equipment being used.
A maximum of two mounts can be provided.
Vision and visual perception
Hearing
Section 9: Communication (spoken)
Current methods of communication
e.g. speech, vocalisations, signing, gestures,
communication board/book, communication
aid etc.
How are ‘yes’ and ‘no’ indicated?
Are these consistent and reliable?
Understanding of spoken language
e.g. Able to follow group conversation
Able to follow complex commands
Able to follow 3+ words commands
Able to follow 1-2 word commands
Unable to follow single word commands
Please include assessment results.
These could be standardised, nonstandardised or criterion referenced
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk
Use of language
i.e. What does the person
communicate?
e.g. Uses a full range of communicative
functions such as requesting, rejecting,
naming, commenting, giving information,
asking questions
Uses some communicative functions
Uses limited communicative functions
Please include assessment results.
These could be standardised, nonstandardised or criterion referenced
How is the language represented?
e.g. pictures, objects, symbols, words
How are these accessed?
e.g. pointing/touch, using switches, using a
mouse or alternative etc.
How is the system organised?
e.g. how many items per page, how many
pages etc.
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk
What are the concerns with the current
communication system?
Section 10: Literacy
Reading Ability
e.g. approximate age equivalent and/or
levels
Able to read extended text for meaning
Able to read paragraphs for meaning
Able to read simple sentences for meaning
Able to read single words for meaning
Unable to read single words for meaning
Writing Ability
e.g. approximate age equivalent and/or
levels
Able to write sentences generated by self
with no assistance
Able to write single words generated by self
with no assistance
Unable to write words
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk
Section 11: Cognition and Learning
Levels of Attention
e.g. very distractible/attention fleeting,
can attend to own activity for a longer period
of time but cuts self off from everything else,
still channelled attention but begins to attend
to others,
single channelled but more easily controlled,
integrated attention for short periods
of time,
integrated attention well established
Does the client have any memory
difficulties?
What activities does the person enjoy,
find interesting or motivating?
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk
Section 12: Team around the individual
Please provide details of those currently involved in supporting the person being referred
and indicate if you wish them to be invited to the assessment by placing a tick in the final
column.
name
postal and
email address
telephone
number
Speech and
Language
Therapist
Email:
Occupational
Therapist
Email:
Physiotherapist
Email:
Teacher
Email:
Personal
Assistant
Email:
Other
Email:
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk
invite
Who has contributed to the completion of this referral?
Name
Role
Data Protection Statement
The information you provide on this form is subject to the provision of the
Data Protection Act 1998. The information will be held confidentially and
will be retained for the purposes of processing your referral and meeting
our statutory obligations.
If you have any queries regarding this service please contact:
Lisa Farrand (Assessment Coordinator)
email: lfarrand@acecentre.org.uk
tel: 0161 358 0151
Steve McCormack (Business Assistant)
email: smccormack@acecentre.org.uk
tel: 0161 358 0151
Many thanks for completing this referral
ACE Centre Hollinwood Business Centre, Albert Street, Hollinwood, Oldham OL8 3QL
tel: 0161 358 0151 fax: 0161 358 0152 www.acecentre.org.uk