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