AAC Intake for School Team

Your student: ______

Dob: ______

Has been referred for a speech-language evaluation at the University of Oregon HEDCO Clinic.We would greatly appreciate your input and expertise to help us determine:

  1. if this is an appropriate referral
  2. what you’ve already been working on.

In addition, our goal is to collaborate with you throughout the evaluation process. We thank you in advance for taking the time to complete this questionnaire to enable us to gain a better picture of your student.

  1. Do you feel exploring the use of AAC tools and strategies is appropriate? Yes No
  1. How does your student currently communicate (please mark all that apply)?
  2. Speech
  3. Verbal approximations
  4. Vocalizations
  5. Sign language
  6. Gestures
  7. Physical leads
  8. Behavior
  9. Pictures
  10. Speech generating device
  11. Other: ______
  1. Why does he/she communicate (please mark all that apply)?
  2. Request
  3. Protest
  4. Direct
  5. Greet
  6. Comment
  7. Share information
  8. Question
  9. Social etiquette
  10. Other: ______
  1. Does yourstudent receive:

speech therapy / yes | no
occupational therapy / yes | no
physical therapy / yes | no
vision supports / yes | no
hearing supports / yes | no
behavior supports / yes | no
after-school tutoring / yes | no
other supports / yes | no Describe:

5. If the student’s primary placement is in a SPECIAL EDUCATION classroom,

How many students are in the classroom? ______

How many assistants are in the classroom? ______

Is the child included in any general education activities? yes | no

6. If the child’s primary placement is in a GENERAL EDUCATION classroom, does the child have a dedicated assistant? yes | no

7. What assistive and/or educational technology is being used in the educational program?

8. Does the child already use an augmentative communication device or mobile device with an app? yes | no If YES, please name the device/app and who owns it.

9. Has sign language been used or is being tried? yes | no

10.Does the student have a manual communication board, book or eye point display?

yes | no

11. If pictures have been used:

  1. How have they been implemented (circle)?

Communication Demonstrating knowledge Picture schedule Other

  1. What type of pictures (circle)?

Photos PCS Symbol Stix Unity Orthography Other

  1. In a field of how many pictures? ______

12. Have any other AAC device(s) been tried or suggested? yes | no

If YES, please describe them:

13.If the child would use a device, what way of operating the device do you think he/she might use? (circle)

point with a finger/thumbpoint with his/her fist

use a light on his/her headlook at the word he/she wants

use a switch to scan to the wordspoint with a head stick

14.If the child is currently using a switch, what kind of switch is it and where is it placed?

  1. Would it be beneficial to have an Occupational Therapist involved in the evaluation for access, positioning, and vision? Yes or No
  1. Please share the ST goals the student is currently working towards.
  1. Please describe the service delivery model of your school program.

18. Would you be interested in attending components of the evaluation? yes | no

19. What final thoughts would you like to leave me with about this student?

Thank you for completing this form!

Completed by:

Phone #

Email:

This document has been adapted with written permission from Gail Van Tatenhove, Pre-AssesmentProtocol.Pediatric.doc, 2013. and Children’s CO, AAC Team