ACES 2016
Augmentative Communication and Empowerment Supports
Potential Funding Sources Worksheet
ACES staff are available to assist you in procuring the funding you will need to attend ACES
and/or for an appropriate speech generating device.
1. Participant’s name: _________________________________________________________
2. Current speech-generating device:
Name/Make/Model: _________________________________________________
Year Purchased:
_________________________________________________
3. I will NOT need assistance in procuring funding. Funding for my participation in ACES will be
provided by:
□ Private Insurance
□ School District
□ Medicaid/Medical Assistance
□ Self
□ Vocational Rehabilitation
□ Combination (list the sources:_____________________________________________)
If you answered question 3, you are finished with this questionnaire. Otherwise, continue
to question 4.
4. I will need assistance in finding funding for (check all that apply)
□ ACES tuition
□ A new speech generating device
□ ACES room/board/PAS/related costs
5. Do you own your current speech generating device?
□ Yes
□ No
If yes, who paid for it?
□ Private Insurance
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□ Medicaid/Medical Assistance
□ Vocational Rehabilitation
□ Self
□ School District
□ Don’t know
□ Combination (list the sources:_____________________________________________)
The following information is for planning purposes only. We will NOT contact any
funding sources without your permission.
I have the following:
6. Private Insurance
□ Have
□ Don’t Have
□ Unsure**
Do you have durable medical equipment (DME) coverage?
□ Have
□ Don’t Have
□ Unsure**
7. Medicaid/Medical Assistance/ACCESS Card (incl: Keystone Mercy, Health Partners, etc.)
□ Have
□ Don’t Have
□ Unsure**
8. Vocational Rehabilitation (OVR)
□ In process of applying
□ Previous Client (Case is closed)
□ Current client, have an IPE
(Individualized Plan for Employment)
□ Unsure**
Name of VR office: _________________________________________________
Name of VR counselor:
Phone Number:
___________________________________________
_________________________________________________
Best time(s) to reach:
_________________________________________________
9. Education
□ Current student enrolled in a public school district
□ Have current IEP
□ Have current transition plan (ITP)
Name of School District: ______________________________________________
Name of Current School: ______________________________________________
Level/grade in School: ________________________________________________
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Anticipated graduation date: ___________________________________________
10. Other Services I Receive:
□ Medicare
□ Private Funding
□ Veterans Administration
□ Other: _____________________
11. Identify an individual who can work with you and ACES staff to secure funding:
Name: ________________________________________________________________
Relationship: ___________________________________________________________
Phone/email: _________________________ / ________________________________
12. If relevant, please identify the Case Manager / Supports Coordinator for your services:
Name: ________________________________________________________________
Company/Organization: __________________________________________________
Phone/email: _________________________ / ________________________________
13.
Identify steps you have already taken to research ACES funding. Please include funding
requests submitted (company/organization, date, result).
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
**If you answered “Unsure” to any of the above questions, or if you have any additional
questions, please contact:
 Jamie Prioli (215-204-5974, Jamie.prioli@temple.edu)
OR
 Russell Goldsetin (215-204-1356, rgoldstein@temple.edu).
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