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SLP AAC Consult Request Form
The student's Speech Language Pathologist (SLP) needs to complete this form prior to the consultation.
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* Indicates required question
First Name of Student
*
Your answer
Last Name of Student
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
District/School
*
Your answer
School's Address
*
Your answer
SLP's Name
*
Your answer
SLP's Email Address
*
Your answer
SLP's Work Phone Number
*
Your answer
SENSORY MOTOR
Hearing:
*
Loss
Nornal
Uncertain
Other:
Vision:
*
Loss
Normal
Uncertain
Other:
Eye Contact
*
Adequate
Fair
Poor
Avoids
Other:
Visual Tracking:
*
Adquate
Fair
Poor
Grasp:
*
Adequate 1
Fair
Unable
Head and Trunk Positioning
*
Adequate
Abnormal
Gross Motor
*
Ambulatory
Poor
Non-Ambulatory
Motor Imitation
*
Unprompted
With Physical Prompt
Completely Assisted
Have you observed any inappropriate behavior(s)? If so, please provide as many details as possible.
*
Your answer
Attentiveness
Attention Span:
*
Adequate
Fair
Poor
Distractible:
*
Almost Never
Occasionally
Frequently
Alertness:
*
Adequate
Moderate
Low
Response Rate:
*
Appropriate
Impulsive
Mild Delays
Moderate Delays
Severe Delays
Awareness of Environmental Events:
*
Adequate
Fair
Poor
Cooperation:
*
Adequate
With Some Prompts
With Numerous Prompts
Resists
Receptive Language
Oral Comprehension:
*
Words
Phrases
Sentences
Simple Conversations
Complex Conversations
Direct Requests
None
Required
Understands Basic Concepts:
*
Functional
Limitations
Poor
None
Required
Concepts Understood:
*
Colors
Body Parts
Shape
Size
Money
Object Function
Prepositions
Categories
Same/Different
More/Less
Opposites/Synonyms
How Many?
Emotions
Physical Property
Time
None
Required
Responds to Name:
*
Yes
No
Sometimes/Maybe
With Physical Prompt
Responds to Attention Commands (e.g., No, Stop, Listen, etc.)
*
Yes
No
Sometimes/Maybe
With Physical Prompt
Looks at Pictures:
*
With Interest
Mildly Attentive
Lacks Interest
Only with Real Photos
Icons
None
Required
Routine Commands:
*
Head Up
Swallow
Push/Pull
Touch It
Hands Down
Turn On/Off
Smile
Hold
Sit
Stand
Come Here
Go
Handshake
Clap
Open/Close Mouth
None
Required
Nonverbal Comprehension:
*
Gestures
Facial Expressions
Body Language
Social Cues
Intonation Changes
Sarcasm
Voice Affect of Speaker
Context
Other's Feelings/Thoughts
N/A Due to Sensory Loss
Required
Two-Dimensional Recognition
*
Photos
Symbols
Requires Large Pictures
None
Required
Expressive Language
Verbal Status:
*
Nonverbal Communicator
Total Communication Communicator
Verbal Communicator
Limited Verbal Communicator
Expressive Level:
*
Single Words
Phrases
Sentences
Conversations
N/A
Methods of Communication:
*
Vocalizations
Speech
Facial Expressions
Eye Gaze/Signal
Gestures
Pointing
Head Nod
Signing
Spelling
Writing
Picture Book/Board
Word Book/Board
Augmentative Communication Device
N/A
Required
Self Expression:
*
Name
Basic Needs
Preferences
Routines
Physical Feelings
Social Changes
Echolalia
Interests
Emotions
N/A
Required
Operates Cause and Effect Item:
*
Unprompted
With Verbal Request
Physically Unable
With Gestural Prompt
With Physical Prompt
No Interest
Repetitive in Nature
N/A
Required
Vocabulary:
*
Extensive
Basic/Functional
Limited
N/A
Required
Pragmatic/Social Language
Communication Intent
*
Request Item/Action
Call/Summon
Compliment/Praise
Deny/Negate
Ask for "More"
Seek/Direct Care
Describe Item
Gain Attention
Express Gratitude
Protest/Resist
Socialize
Request Assistance
Inform about Self
Apologize
N/A
Required
Initiates Communication:
*
Appropriately
Moderatley
If Asked/Prompted
Rarely
None
Answers "Wh" (Who, What, Where) Questions:
*
Consistently
Inconsistently
Minimally
Not Able
Answers "When, Why, and How" Questions:
*
Consistently
Inconsistently
Minimally
Not Able
Answers "Yes/No" Questions:
*
Consistently
Inconsistently
Minimally
Not Able
Ask Questions:
*
Simple Forms
Complex Forms
Not Able
Conversational Topics:
*
Of Mutual Interest
Self-Centered
Perseverative
None Initiated
Required
Turn-Taking:
*
Appropriate
Needs Cues
Unable
Topic Initiation:
*
Independent
With Occasional Assistance
N/A- No Means
Reading/Literacy:
*
Letters
Name
Numbers
Key Words
Survival Words
Phrases
Paragraphs
Store Signs
None
Required
Writing/Spelling:
*
Letters
Name
Numbers
Key Words
Phrases
None
Required
Speech
Understood By:
*
Familiar Others
Trained Listeners
Average Listeners
All Listeners
No One
Required
Adjusts Speech to Improve Understanding:
*
Successful
Self-Corrects
Sometimes
Rarely
Nonverbal
Sounds Produced:
*
Beginning (vowels p, b, m, h, w, n, ng)
Intermediate (y, k, g, f, d)
Advanced Intermediate (t, ch, r, sh, s v, l)
Advanced (th, j, zh, wh)
Consonant Blends
Nonspeech Sounds
Required
Dentition:
*
Unremarkable
Overbite
Repaired Cleft
Some teeth are missing
Absent
Poor Condition
Required
Oral Motor Imitation:
*
Able
Inconsistent
Unable
Voice
Loudness (Volume)
*
Adequate
Excessive
Inadequate
Nonverbal
Voice Quality
*
Normal
Nasal
Hoarse
Strained
Whispered
Nonverbal
Oral
Drooling
*
Absent
On Occasion
Frequently
Not Observed
Tongue Thrust
*
At Rest
On Swallow
During Speech
Not Observed
Swallowing and Diet
*
Aspiration Risk
Adequate Chew/Swallow
Pureed Texture
Uses Adaptive Equipment
Other:
Required
Fluency
Fluency:
*
Adequate
Repetitions
Nonverbal
Rate of Speech:
*
Appropriate
Too Rapid
Labored/Slow
Nonverbal
Non-Oral Communication
Use of Sign Language:
*
For Communication
On Command
Emerging
Imitated
With Physical Prompt
Not Stimulable
Not Needed
With Motor Limits
N/A
Required
Sample Signs:
*
Your answer
Express Yes/No:
*
Head Nod
Signs
Symbols/Pictures
Verbalizes
Not Able
Required
Fine Motor Abilities
*
No Limitations
Fair
Poor
N/A
Parental Concerns
Please provide any concerns that the parents/guardians have addressed in regards to the child's communication.
*
Your answer
Summary
Results of Tests/Assessments:
*
Your answer
Current Communication Goals/Objectives:
*
Your answer
Communication Strengths:
*
Your answer
Communication Limitations:
*
Your answer
Interventions/Strategies that you have already attempted/implemented:
*
Your answer
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