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Augmentative and Alternative Communication (AAC) Assessment for Philadelphia IDS Consumers The Institute on Disabilities at Temple University is available to conduct Augmentative and Alternative Communication (AAC) assessments, using qualified, licensed speech-language pathologists (SLPs). Assessments may be completed for individuals with disabilities and communication needs who are served by Philadelphia IDS. Please note: This service is only available to Philadelphia IDS consumers aged 21+ As a result of this service, recommendations will be provided to individuals with disabilities, their families, and other team members. Recommendations may include: Strategies to increase opportunities for communication and increase the likelihood of successful communication Supports for the implementation of AAC strategies Ways in which AAC may help establish functional communication (including, but not limited to, speech-generating devices) Identification of related assistive technologies (e.g. for telephone communication) Assistance with acquiring AAC devices or other assistive technology devices and services. To submit your request for Augmentative and Alternative Communication (AAC) assessment Complete and return this form (along with relevant ISP pages) using fax, regular mail or via an encrypted email/file sharing, such as https://tusafesend.temple.edu/ Kathryn Helland, MS, CCC-SLP Augmentative Communication Services Coordinator Encrypted: https://tusafesend.temple.edu/ Email: [email protected] Fax: 215-204-6336 (Attn: Kathryn Helland) Institute on Disabilities at Temple University Attn: Kathryn Helland /1755 N 13th St, Student Center, Rm 411 S / Philadelphia, PA 19122 Please contact your agency’s Communication Champion or Kathryn Helland by e-mail ([email protected]) or phone (215-204-3032) if you have questions about this process. Revised 1/2016 AUGMENTATIVE AND ALTERNATIVE COMMUNICATION EVALUATION REQUEST Philadelphia County IDS Consumers ONLY Consumer’s Name Birthdate: GENERAL INFORMATION Today’s date Gender Language(s) Spoken Male Female Street Address Telephone City, State, Zip Email Type of Residence Family Home Other________________ Residential Agency Community Living Arrangement Contact’s Phone Residential Contact Contact’s Email Supports Coordinator (SC) SCO’s Phone SCO/Agency SCO’s Email *All scheduling will be done through the SC. Please star the best way to reach the SC. Revised 1/2016 PRESENT VOCATIONAL OR DAY PROGRAM SETTING Work/Day Program Agency Contact Person Street Address Contact’s Phone City, State, Zip Contact’s Email Activities/Duties Hours attended Please attach a copy of all relevant pages of the ISP. ~ Include Plan Summary, Individual Preference (Know & Do), Behavioral Support Plan (if applicable), and Functional Information (Communication, Understanding Communication), etc. Referral made by Relationship to consumer Reason for referral Please check any that apply: Recent change in communication status Family or advocate request Needs updated evaluation Change in behavioral profile Recent transition Past history of device use (no longer used/ working) Additional relevant information Revised 1/2016 Page 2 of 6 Medical Diagnosis/es MEDICAL INFORMATION Speech Diagnosis/es Date of last Vision test/screen Results Date of last Hearing test/screen Results COMMUNICATION INFORMATION Estimate the frequency of each communication method used along with how frequent any prompts/cues are needed with it. Please enter R (Regularly), S (Sometimes) or N (Never) Frequency COMPREHENSION Responds to speakers Understands what is said to him/her Prompts/Cues Needed Follows routine, 1-step directions Follows simple, multi-step directions Frequency Please enter R (Regularly), S (Sometimes) or N (Never) then describe. Frequency Frequency EXPRESSION with with How?/What? Familiar Unfamiliar (Please describe) Listeners Listeners Makes needs and wants known Initiates communication Speaks in words, phrases or sentences How many words? Speech is easily understood (if applicable Writes or types Uses gestures to communicate Revised 1/2016 Page 3 of 6 Uses facial expressions, body language or other behaviors Uses a communication board/book What? Uses speech-generating /communication device Client can recognize (check all that apply): objects photos pictures line drawings Make choices between 2 items more than 2 items pictures activities What does the client communicate about? What are the most important communication needs at home? What are the most important communication needs in the vocational/work setting? What has already been tried to improve communication? And, how did it go? What results/information do you hope to gain as a result of this consultation or evaluation? What are the consumer’s favorite topics and activities? Is there anything else I should know about your consumer? Complete and return this form (with relevant ISP pages, as described above) to Kathryn Helland or encrypted: https://tusafesend.temple.edu/ Email: [email protected]) or Fax (215-204-6336) Revised 1/2016 Page 2 of 6