JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
AAC Evaluation Request (parent)
This form is to be completed by the parent of the student.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Student's Name*
*
Your answer
School District and Building Name
*
Your answer
Parent(s) or Guardian(s) Name
*
Your answer
Please provide an email address where you can be reached.
Your answer
Please provide a phone number where you can be reached.
*
Your answer
What are your expectations for this consultation?
Your answer
Your child's current communication method:
Gesture/Facial Expression
Verbalization
Sign Language
Picture Cards
Electronic Device
Word or sign approximation 1
Single word
Phrase level
Sentence level
Gesture/Facial Expression
Verbalization
Sign Language
Picture Cards
Electronic Device
Word or sign approximation 1
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 (toilet, hunger, etc.)
Makes wants known (play, TV, etc.)
most of the time
some of the time
never
Not understood at all
Understood by experienced listener
Understood by unfamiliar listener
Makes needs known (toilet, hunger, etc.)
Makes wants known (play, TV, etc.)
What does your child do when not understood?
Check all that apply.
Quits trying
Repeats message
Expands or changes message
Gets angry
Other:
What are your child's favorite activities or interests?
Your answer
Please add any other pertinent information.
Your answer
If possible, please send a short video of your child communicating at home to Kim at
kjm@bviu.org
.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
