Parent/Guardian Augmentative Alternative Communication (AAC) Consult Request Form

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This form must be completed by the parent/guardian of the student prior to the consultation.

Student's First Name *

Student's Last Name *

School District and Building *

Name of Parent(s)/Guardian(s) *

Email address where you can be reached? *

Phone number where you can be reached? *

What are your expectations for this consultation? *

What is your child's current communication method? *

Gesture/Facial Expression

Verbalization

Sign Language

Picture Cards

Electronic Device

Word or Sign Approximation

Single Word

Phrase Level

Sentence Level

Indicate your child's success with his/her current communication method: *

Most of the time

Some of the time

Never

Not understood at all

Understood by experienced listener

Understood by unfamiliar listener

Makes needs known (e.g., toilet, hunger, etc).

Makes wants known (Play, Watch TV, etc).

What does your child do when he/she is not understood? Check all that apply *

Quits trying

Repeats message

Expands or changes message

Verbal aggression (screaming, threatening, etc.)

Physical aggression (towards him/herself or other people).

Other:

Required

What are your child's favorite activities or interests? *

Pease add any other pertinent information.

Video: If possible, please send a short video of your child communicating at home to Mr. Nick Pollio:

nicholas.pollio@bviu.org

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