ILC Tech Referral –Communication / AAC

Thank you for providing the following information. This general information will allow our team to prepare for your appointment and ensure the relevant equipment is available.
Client Information
First Name*: / Last Name*:
Date of Birth*: / Age
Suburb*: / Street Address:
Phone Number*: / Email:
Country of Birth: / Main Language Spoken:
Funding / Eligibility (tick or circle all applicable):
Disability Support Pension / Aged Care Pension / Health Care Card / DVA Card
NDIS / WANDIS / Better Start / Helping Children with Autism / Enhanced Primary Care
Home and Community Care (HACC) / Commonwealth Home Care Package /
Private Health Insurance
Other:
Primary Diagnosis:
Other Relevant Medical History:
Weight*: / Height*:
Mobility: eg. method of mobility, equipment used, level of assistance required
Transfer Ability:eg. method of transfers and level of assistance required
Communication: eg. difficulties with hearing, vision, speech, devices used, level of assistance required
Carer / Parent / Alternate Details (please circle)
First Name: / Last Name:
Relationship to client:
Phone Number: / Email:
Primary Therapist / School / Support Agency Details (please circle)
First Name: / Last Name:
Position: / Organisation:
Phone Number: / Email:
Reason for Referral
Summary of why the referral has been sent. What equipment category / type do you wish to view?
What are the difficulties the client is having? What are their strengths / abilities?
Include any relevant details relating to the person, their carers and environment.
Current Equipment Used
What relevant equipment is the client currently using? Why is this not sufficient?
Is an interpreter required? (Please list specific language/ AUSLAN)
Accessing a communication system
  1. Please describe as relevant the client’s:
VisionHearing
Visual perception Auditory perception
Fixing/tracking with their eyesLocalising to sound
  1. How could the client most reliably and consistently access a communication system?
Direct finger pointing Jelly bean switch and scanning
Direct finger pointing with a key guard Head switch
Pointing with a fist Eye gaze
Please describe:
If any access points have already been trialed, please provide further information:
  1. Please describe the client’s gross motor skills. Do they (please tick all that apply):
Walk independently
Walk aided (e.g. frame, walker)
Use a wheelchair
Language
  1. Please provide information on the client’s current receptive language skills:
  1. Can the client communicate yes/no reliably? How do they indicate this?
  1. How does the client currently express themselves? (please tick all that apply):
Pointing Facial expression
Vocalizing High tech Communication system
Single wordsLow tech communication system
GesturesSigning
Other
Please attach any formal language or AAC assessments (LINK)
  1. Describe the client’s interaction (tick all that apply):
Displays interest in the environmentUnderstands cause-effect
Attend to language/the environment/taskTake turns in an interaction
Attend within a distracting environment
Make eye contact
  1. Please comment on barriers to communication (e.g. behaviours, attention and listening skills, memory and/or learning):
  1. Please comment on barriers to using technology
  1. List activities/objects/people that the client finds motivating or interesting:

Alternative and Augmentative Communication Systems
  1. Has the client been exposed to, or used, any of the following communication systems? (please tick all that apply):
Low tech systems / High tech systems
Key word sign/Makaton / iPad and communication apps
Communication book / Single meaning symbols on a Speech generating device
Communication (ALS) Board / Whole phrase messages on a Speech generating device
PODD book / Semantic compaction systems (e.g. minspeak)
PECS / Alphabet based systems
Other / Other
Please describe (which apps, how long system has been used, how successful, symbol layout e.g. 12 cells, type of symbols used e.g. PCS, SymbolStix, Minspeak, size of symbols):
  1. What core (frequently used words e.g. ‘eat’, ‘more’, ‘hot’, ‘good’) and fringe vocabulary (less frequently used words e.g. ‘) does the client use/would be most useful for them to be able to communicate:
Core vocabulary:
Fringe Vocabulary:
  1. What features of an AAC system would be important for the client (please tick all that apply):
PortabilityMounting
Durability
Please describe:
Additional Appointment Requests:
Preferred date / day / time*:
Who will be attending appointment?:
Referrer Details
First Name*: / Last Name*:
Relationship to client*: / Best contact*
Date of Referral*:

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