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Utah Augmentative Alternative Assistive Communication Technology Team REFERRAL FORM STUDENT AGE/DOB PHONE ADDRESS PARENT/GUARDIAN DATE SCHOOL DISTRICT/TEAM None Referral Source/Contact Person School Address School Phone Diagnosis Approximate Cognitive Functioning Level Program Placement Reason for Referral What do you hope to gain from this referral/assessment HEALTH CONCERNS Hearing status Visual functioning Seizures frequency duration etc. Medications Overall health status COMMUNICATION CONCERNS List student s current means of communication and/or attempts to communicate and/or make needs known i.e. signs gestures communication aide symbol systems vocalizations. How successful are communicative attempts Do you believe the student gets frustrated Are there persons within this environment with whom the child may communicate effectively Please describe. Does the student indicate yes and no If so please describe. Do you believe the student understands more than he/she is able to express Why Are there activities in your class which you feel the student cannot participate in or participate equally in due to speech involvement Please describe. What would you consider the greatest obstacle for the student in terms of academic achievement Please describe. Can the student match check those that apply Object to object Object to Photo Picture Drawing Photo Drawing to Object Check items below which student can identify by pointing or looking when named Object Written Words Other specify Written Communications 1. List the student s current means of written communication* Are some methods of writing more effective than others Please describe. required Please describe. MOTOR CONCERNS How is the student positioned throughout the day If the student is in a wheelchair what type and with what adaptations Briefly describe gross motor functioning abilities i*e* head and trunk control mobility skills independent some support total support. position Accurate reach Accurate point Isolated finger movements Cross midline with gaze Which is the student s preferred hand not applicable OTHER IMPORTANT INFORMATION 1. What are the interests of the student 2. What types of toys/hobbies does this student enjoy 3. What motivates this student 4. How successful are communicative attempts Do you believe the student gets frustrated Are there persons within this environment with whom the child may communicate effectively Please describe. Does the student indicate yes and no If so please describe. Do you believe the student understands more than he/she is able to express Why Are there activities in your class which you feel the student cannot participate in or participate equally in due to speech involvement Please describe. Does the student indicate yes and no If so please describe. Do you believe the student understands more than he/she is able to express Why Are there activities in your class which you feel the student cannot participate in or participate equally in due to speech involvement Please describe. What would you consider the greatest obstacle for the student in terms of academic achievement Please describe.

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