Client’s Name:
GSTT Assistive Communication Service
Referral Form: Adult
Please read acceptance criteria carefully prior to making a referral.
Please phone 0203 049 7751 or email gst-tr.acs-hub@nhs.net to discuss any queries.
Acceptance Criteria
An individual who is eligible to access a specialist Assistive Communication Service (ACS) has the
following:

a severe/complex communication difficulty associated with a range of physical, cognitive,
learning, or sensory deficits

a clear discrepancy between their level of understanding and ability to speak
In addition, an individual must:

be able to understand the purpose of a communication aid

have developed beyond cause and effect understanding
And should:

have experience of using low tech Augmentative and Alternative Communication (AAC) which is
insufficient to enable them to realise their communicative potential
Exclusion criteria:




Not having achieved cause and effect understanding
Have impaired cognitive abilities that would prevent the user from retaining information on how
to use equipment
Ability to use a standard touch screen or keyboard with literacy based software
Preverbal communication skills
Please note: It is essential that a key community therapist is present throughout the
assessment process, that they are able to provide regular support to the client, monitor
the use of equipment and take part in the assessment review.
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SECTION 1: GENERAL CLIENT INFORMATION
Name:
Address:
Tel:
Mobile:
Funding Borough:
Date of Birth:
NHS Number:
Ethnicity:
Gender: Male
GP Address:
GP Telephone Number:
Female
DETAILS OF DIAGNOSIS:
Primary Diagnosis:
Date of onset:
Stable
Deteriorating
Improving
Other significant medical history, if any:
SECTION 2: REFERRER’S DETAILS
Name
Profession
Address
Relationship to client
Phone Number
E-mail
Date
REASON FOR REFERRAL:
Please give detailed information of what goals the person and referrer would like to achieve from
this referral:
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KEY PEOPLE INVOLVED – CARERS AND PROFESSIONALS AND CONTACT NUMBERS
Family:
Carer:
Friends:
Who will support the Client with equipment trial/use?
CONSENT
The Client consented to this referral? Y
N
If consent has not been given, please explain the reason:
If this was a best interest decision, who made this decision?
SECTION 3: PHYSICAL ABILITIES
Please describe the person’s ability to use their upper limbs, including their fingers, hands and
arms (e.g. tremor, spasticity, tone and active range of movement).
Give examples of what activities the person can/cannot do with their hands.
Please comment on the client’s head control.
Please describe the person’s mobility. Are any of the following used?
Manual wheelchair
Model, if known _
__________________________
Powered wheelchair
Model, if known__
_________________________
Waling aids (frame/ crutches)
Walking unaided
What seating is used for the majority of the day? (eg riser-recliner armchair/tilt in space
wheelchair/bed.)
Manual wheelchair
________________
Powered wheelchair
Armchair
Bed
Other
SECTION 4: EMOTIONAL STATE/CONTROL
Describe any emotional / psychological factors which may affect the assessment.
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How does the client respond in frustrating situations?
SECTION 5:SENSORY FUNCTION
Give details of visual difficulties.
Are glasses required? Y
Give details of hearing difficulties.
N
Are hearing aids in place? Y
N
SECTION 6: COGNITION
Please give details of any cognitive/learning disabilities which might impact on the ability to
learn to use new equipment:
LITERACY
Can the Client read?
Y
N
Can the Client write?
Y
N
Can the Client use symbols?
Y
N
SECTION 7: COMMUNICATION
How does the person communicate currently:
What strategies help?
Does the person have a reliable YES/NO?
Y
N
If Yes, how do they express YES/NO?
Speech Therapy Diagnosis:
Where does the person wish to communicate?
With whom does the person wish to communicate?
What low tech communication methods have been trialled?
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Which systems were successful and why?
Which systems were unsuccessful and why?
What HIGH TECH communication methods have been trialled?
Which systems were successful and why?
Which systems were unsuccessful and why?
Client’s first language:
Will an interpreter be required?
Y
N
SECTION 8: COMPUTER USE
Describe the client’s previous experience of using computers / tablets:
Does the person have access to a computer at the moment?
Y
N
Does the person have access to a tablet at the moment?
Y
N
SECTION 9: ADDITIONAL INFORMATION
NB. Where possible, we ask clients to travel to the Bowley Close Centre for appointments, as this
enables our team to provide a comprehensive assessment with access to a full range of
assessment equipment.
Will this be possible for the client? Yes
No
Please provide as much detail as possible and any relevant reports, e.g. outcome measures of
equipment trials, communication reports, medical reports and so forth.
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Guy’s and St Thomas’ Assistive Communication Service
Guys and St Thomas’ NHS Foundation Trust
Community Health Services
Bowley Close Rehabilitation Centre
Farquhar Road
London
SE19 1SZ
Tel: 0203 049 7751 Fax 0203 049 7703
E-mail: gst-tr.acs-hub@nhs.net
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