Specialist Augmentative and Alternative Communication (AAC)
Assessment
Children and Young Person’s Referral Form
Name: Error! Reference source not found.
D.o.B.: Error! Reference
source not found.
NHS Number: Error! Reference source not
found.
Please tick the appropriate box:
Service requested
Provision only
Assessment and Provision
Consultation
Area
Is your patient registered with a GP in:
East Sussex
West Sussex
Surrey
Brighton & Hove
Other
If “other” please state: :
Please Note:
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Prior to submission of this referral form you are required to:

ensure that your client meets the Specialist Service Criteria which can be viewed
on our website
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By submission of this referral form you have agreed with our joint working model,
including provision of support/ training to the client and their network of support
-
If your referral is to access the “provision only” service, please fill in sections 1-3, 12
and 13 only.
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You can either print this form for completion and post it to the address at the foot of
the page or save this form on your computer, type the required information in the
grey boxes and securely e-mail it to: SC-TR.ChaileyAACservice@nhs.net
1. Personal information
1.1 Client Information
Male
Gender
Female
Home address
Post code
Home telephone &/or
Mobile
Preferred method of
contact e.g. Email
GP’s name
GP’s address
1.2 Referrer
Name
Address
Telephone
Email
(Please provide your nhs.net email where possible)
1.3 Please give details of professionals involved
Next of Kin
Name:
Telephone:
Relationship:
Address:
Aware of the referral?:
Speech and
Language Therapist
Name:
Occupational
Therapist
Name:
School:
Address 1:
Telephone:
Aware of the referral?:
Telephone:
Aware of the referral?:
Telephone:
Teacher/key contact:
Aware of the referral?:
Telephone:
Address 2 (if relevant):
Teacher/key contact:
Aware of the referral?:
Other
Role:
Telephone:
Name:
Aware of the referral?:
Key person/s for
supporting the client
with AAC
Name:
Address:
Aware of the referral?:
Name:
Address:
Aware of the referral?:
Please state who is
the best person to
liaise with should we
need to organise an
assessment.
Name:
If details are not provided above please give details here:
Role:
Telephone
We will send the
appointment letter to
the client and the
referrer. Is there
anyone else you
would like us to invite
to the appointment?
*please ensure the
client/ their parent or
guardian consents to
these people attending
the appointment
2. Expectations
2.2 What does the client
& their family hope to
achieve from this
referral?
(Please be specific)
2.3 As the referrer what
are your goals of
intervention?
2.3 What tasks do the
school expect this child
or young person to be
able to do using AAC
that is currently difficult
for them to achieve?
If you have selected the “Provision Only” and meet the criteria to request this service
please go to section 11.
3. ………………..
Diagnosis
Any further
diagnoses/significant
medical history that may
be relevant for
assessment
3.1 Please describe any
cognitive/ behavioural
issues that could impact
upon assessment/
provision. The
information in this section
should include areas such
as motivation, memory,
attention, following
instructions and ability to
learn new skills.
3.2 Please let us know if
there are any visual,
hearing, or other
sensory difficulties
Yes
3.3 Please let us know if
there are any tissue
trauma or pain issues
Yes
No
If “Yes” please provide more details:
No
If “Yes” please provide more details:
3.4 Please describe the client’s posture and any changes in movement, quality
of movement and/or tone; including range of movement, amount of physical
effort required, spasticity etc… Please comment on the client’s physical
abilities and voluntary movement in the following areas;
Head/chin
Right
Left
Eyes
Arms
Hands
Knees
Feet
3.5 If access is an issue
please provide us with a
video of the client using
any Low/High Tech
communication aid,
accessing their
computers or any other
AT device. Please refer to
video guidelines for
support.
Access is not an issue and this is not applicable
Access is an issue
- Video was attached to the referral or will be sent/
has been sent separately
- I am unable to provide a video
If unable to provide a video please state your reasons:
3.6 Please list any other
clinics e.g.
posture/seating clinics
attended in the last 2
years and any relevant
outcomes
3.7 Are you awaiting any
equipment that may
affect the assessment
e.g. seating system or
spinal jacket that may be
used for functional
activities during the
course of the
assessment?
3.8 Are you awaiting any
medical interventions
that may impact on the
outcomes of this
assessment?
3.9 Please list any
relevant medication that
your client is currently
taking.
4. Seating, Positioning and Mobility
4.1 In which seating does
your client carry out most
of their functional
activities?
4.2 To your knowledge in
which position does your
client function best?
4.3 Please describe how
the client moves around,
both inside and out?
4.4 If a powered
wheelchair is in use,
please give details to
indicate how the chair is
controlled e.g. joystick,
switches?
5. Communication
5.1 Speech and
language
formal/informal
assessments
Please provide the following information and submit the
reports from any formal/ informal assessments if
available.
Date
Type of test Results
1.
2.
3.
4.
5.2 How does the client
communicate a reliable
“Yes” and “No”?
If not reliable please
state.
5.3 Please indicate which methods of communication are used. Please make
reference to speech, body language, facial expression, gesture, eye pointing,
vocalisation, writing, symbols, picture, photographs, and drawing objects as
appropriate.
Please describe “how” below
Gain attention
Yes
No
Express wants/
needs
Yes
No
Make choices
Yes
No
Refuse/ decline
Yes
No
Protest/ Resist
Yes
No
Ask questions
Yes
No
Provide
information
Yes
No
Repair
conversation
Yes
No
5.4 Is signing
used?
Yes
No
If “Yes”, which sign language is used?
6. Cognitive and Language Skills
Is the child or young person operating at ‘P levels, or is there evidence of significant
delay in the areas of Literacy, Numeracy, Language Comprehension and Expressive
language?
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If yes, complete all sections of the profiles in sections 6.1 to 6.4:
If no, please complete the boxes in summary of student’s abilities and concerns
relation to the child or young person where you think it applicable
6.1 Numeracy (Please tick all that apply)
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Engages in joint attention with
adult (for example number songs,
stories, games)
Shows an interest in number
activities with adults
Shows an awareness of number
activities and counting rhymes and
songs
Follows a sequence of pictures or
numbers
Joins in with familiar number
rhymes, songs and games
Shows an awareness of
contrasting quantities (for example,
‘one’ and ‘lots’)
Understands one-one
correspondence (for example,
matching cups to saucers)
Demonstrates an understanding of
‘more’ (for example, more cups are
needed)
Demonstrates an understanding of
‘less’ (for example, which bottle
has less water)
Picks out described shapes from a
collection
Recognises differences in quantity
(for example, which group as more
or less)

Can indicate ‘one’ or ‘two’
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Joins in rote counting to 5
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Makes sets of up to 3
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Joins in rote counting to 10
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Recognises numerals from 1 to 5
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Joins in rote counting beyond 10
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Continues to rote count onwards
from a given small number
Recognises numerals from 1 to 9
and relates them to sets of objects
Understands ordinal numbers (first,
second, third)
Estimates a small number up to 10
In practical situations can respond
to ‘add one’ or ‘take away one’
Please summarise how the child or young person demonstrates the skills listed in Section
6.1. For example, this could be by pointing to flash cards, eye-pointing on an E-tran frame,
using a switch to scan and select.
If the child or young person is making a selection, for example from cards on an
E-tran frame, please state how many choices are presented and how much
support is given. For example, they can identify which number comes ‘next’ in a
given sequence by eye-pointing to the correct number from a choice of 4.
Please summarise how the child or young person joins in with number rhymes
and so on. For example, this could be signing or using natural gestures.
Summary of student’s abilities and concerns related to numeracy:
6.2 Literacy (Please tick all that apply)
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Engages in joint attention with
adult (for example, songs, stories,
games)
Shows an interest In books and
stories with adults
Understands how books work
Shows an interest in looking at
books
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Recognises environmental print
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Matches letters and short words
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Associates pictures with spoken
word when being read to
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Realises text conveys meaning
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Recognises connection between
spoken words and specific text
when read to
Predicts elements of a narrative
(for example, what comes next)
Understands conventions of
reading (for example, following text
from left to right)
Applies phonic rules when
attempting to decode words
Blends sounds to make words
Reads a number of familiar words
or symbols
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Writes (or types) emergently
When asked to spell a word, gets
first phoneme correct
When asked to spell a word gets
first and last phoneme correct
Makes phonetically plausible
attempts at spelling words
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Can spell words with some
accuracy
Can produce other single words
Groups letters and leaves spaces
between them as though writing
words
Forms short phrases
Can produce sentences
Recognises at least had the letters
of the alphabet by shape, name or
sound
Can produce single key words (for
example, their name)
Please summarise how the child or young person demonstrates the skills listed in Section
6.2. For example, this could be by pointing to flash cards, eye-pointing on an E-tran frame,
using a switch to scan and select.
If the child or young person is making a selection, for example from cards on an
E-tran frame, please state how many choices are presented and how much
support is given. For example, they can identify which number comes ‘next’ in a
given sequence by eye-pointing to the correct number from a choice of 4.
Please summarise how the child or young person joins in with number rhymes
and so on. For example, this could be signing or using natural gestures.
Summary of student’s abilities and concerns related to numeracy:
6.3 Comprehension (please tick all that apply):
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Reacts to a range of people,
familiar and unfamiliar
Reacts when sees familiar objects
Reacts when people speak
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Shows an anticipation of a familiar
activity or event
Reacts to new experiences and
activities
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Reacts to own name
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Recognises some photos
Demonstrates understanding of
names of familiar or motivating
objects or activities
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Recognises some pictures
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Recognises some symbols
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Can sort objects into categories
Demonstrates understanding of
names of familiar people
Shares an activity with someone
else
Understands what they do has an
impact
Demonstrates an awareness of
others
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Reacts to changes in tone of voice,
facial expression and body
language
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Tracks sounds or visually
interesting objects

Recognises some objects

Can sort symbols into categories
Can point or look to tell or label, for
example ‘Where’s the dog?’
Can match symbol/picture to
picture/symbol
Can match object to symbol or
picture
Demonstrates understanding of
cause and effect
Recognises some signs
Is the child or young person able to:
Understand sentences with 2 information carrying words, for example “Where is the boy’s
hat?” (Choices required for underlined words)
If applicable, please give an example:
Understand sentences with 3 information carrying words, for example “Where is the boy’s
red hat?” (Choices required for underlined words)
If applicable, please give an example:
Understands some prepositions
If applicable, please give an example:
Understands some negatives
If applicable, please give an example:
Understands some questions
If applicable, please give an example:
Please summarise how the child or young person demonstrates the skills listed in Section
6.3. For example, summarise an activity where you are confident the child or young person
understands the meaning of the language used.


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Do they rely on this being a regular event or do they understand the
language in a new activity?
How much support do they need from signs or objects or pictures or
symbols; do they understand the signs or objects or pictures or symbols
when you do not say the word when showing the objects or pictures or
symbols?
How do you know that they understand the language or the representation
of (object, picture or symbol)?
Does the child or young person demonstrate their understanding with facial
expression, gesture, body language, yes or no response, pointing, eyepointing?
Which sign and which symbol system does the child understand?
Summary of student’s abilities and concerns related to understanding of language:
6.4 Expression (please tick all that apply):
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Shows intent to communicate by
looking at, reaching for or touching
Can hold gaze on a person or
object in question
Moves gaze or attention between
person and abject in question
Shows pleasure when
communication attempt is
successful
Shows displeasure when
communication attempt s not
successful
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Can initiate interaction
Can sustain interaction
Motivated to communicate
Consistent yes response
Consistent no response
Can communicate clear likes and
dislikes
Able to use some signs
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Can look at ‘empty hands’ with
different labels for choices
Uses objects to communicate
Uses pictures/photos to
communicate
Uses symbols to communicate
Uses written words to
communicate, relies on the
communication partner saying the
words as they show or point to the
object, picture, photo or symbol
A non-preferred/don’t like/blank
offered alongside
Can communicate spontaneously
Can combine symbols with prompt
Can combine symbols without
prompt
Uses communication book (please
include example pages with this
referral)
Can gain attention
Is the child or young person also able to:
Use single symbols
If so, how are these presented, how many at a time, how big?
Use vocalisations
If so, how are these presented?
Which of the following language functions does the child or young person use? (Please tick
all that apply):
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Expresses wants
Expresses dislikes
Greets
Gives information
Directs person or activity
Comments
Reasons or negotiates
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Expresses likes
Requests something
Requests more
Describes something or someone
Asks questions
Repairs misunderstandings
Expresses feelings
Please summarise how the child or young person demonstrates the skills listed in Section
6.4 For example, this could be pointing, touching, eye-pointing.
Are unfamiliar communication partners able to understand the child or young
person’s communication? Which sign and which symbol system does the child or
young person use? Please give an example of when, where, with whom and about
what the child or young person is best at communication.
Summary of student’s abilities and concerns related to expressive language:
7. Current and previous experience of using technology and/or
consumer electronics
7.1 How familiar is your
client with technology? for
example client was using/
uses a computer, iPad,
smartphone,
Environmental Control
System, etc… regularly.
Please include if the client
uses/d a computer, smart
phone, iPad, iPod, Tablets
or Environmental Control
and other technology.
If this technology is no
longer in use how long ago it
was used.
If your client is not familiar
with technology is
someone regularly
available to support them?
Yes
No
N/A
Please state name
and relation to the client
8. Current and previous experience of using low and high tech AAC
Please give details and evaluation of resources that have been used in the past and are
currently in use for the child or young person.
(Please complete all that apply):
Resource
(specify what/where
used/what for)
None
Paper or low tech
communication
book/boards/activity sheets
Low tech writing aids
Used Previously
Summarise how this is
being used currently
Computer/laptop/tablet
Light tech digital speech
output
(e.g. Go Talk)
Speech recognition (for
computer software)
Hi-Tech Augmentative and
Alternative Communication
system
Free iPad/tablet based
resources that are noncustomisable
Other iPad/tablet based
resources that have been
customised for the child or
young person
Word prediction
Curriculum software relevant
to request need (e.g. Clicker
or ChooseIt!)
Alternative access (e.g.
joystick adapted mouse or
switches)
Access setting on computer
hardware (e.g. filter keys,
onscreen keyboard)
9. Interests and activities
9.1 Please describe/
outline the client’s
interests and activities.
Please include an outline
of the client’s routine
activities
10.
Additional information
10.1 Is there anything
else you wish to add
which would help us to
get a broader picture of
the client’s abilities?
10.2 To your knowledge
are there are any health
and safety or
safeguarding issues that
we need to be aware of?
Yes
No
If “Yes” please contact us to discuss this in more
details.
Please refer to our guidelines for advice and examples.
11.
Request form for communication aid (“Provision only”)
This section of the form is to be used by therapists with extensive experience of AAC.
Please check our list of available equipment through provision only. If you already have a
specific communication aid in mind for your client, please fill in the details below:
11.1 What AAC options
have you considered
and/or discussed with your
client?
11.2 Please state your
clinical reasoning for
choosing this device and
vocabulary package i.e.
app?
11.3 What low tech AAC
will be provided as a
backup where applicable?
11.4 How will your client
access the device?
Where your client’s physical
needs are likely to change
(e.g. rapidly progressive
conditions) or if you have any
concerns relating to access
please consider discussing
the case with us, or use our
assessment service to ensure
their changing needs are met.
11.5 Please include details
of the aid and accessories
to be ordered in this
section. (If mounting to a
wheelchair is required an
assessment will need to be
carried out.)
11.6 If the device you are
requesting is keyboard
based e.g. lightwriter
please select the
appropriate option.
QWERTY Keyboard
ABC Keyboard
11.7 If your request is for
an iPad, iPhone or iPod
please provide the client’s
email address that is
associated with their
iTunes account so that the
relevant app can be gifted
to the account.
11.8 Do you require training
for delivering the device to
the client?
12.
Yes
No
Referrer
I understand that this referral is the first stage in the application process for support from the
Chailey Heritage Specialist AAC Service and submission of this form does not guarantee
that support will be provided.
If this application is successful, I understand that the client may require additional equipment
and on-going human resources, such as community therapist support, Care Assistant time
or technical support, which will not be provided by the Chailey Heritage Specialist AAC
Service.
Print Name:
Date:
Monday
AM
Referrer
Client/Carer/
Family
PM
Tuesday
AM
PM
Wednesday
AM
PM
Thursday
AM
PM
Friday
AM
PM