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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First Name of Student *
Last Name of Student *
Date of Birth  *
MM
/
DD
/
YYYY
District/School  *
School's Address *
SLP's Name *
SLP's Email Address *
SLP's Work Phone Number *
SENSORY MOTOR 
Hearing:   *
Vision:  *
Eye Contact *
Visual Tracking:   *
Grasp:  *
Head and Trunk Positioning *
Gross Motor *
Motor Imitation *
Have you observed any inappropriate behavior(s)?  If so, please provide as many details as possible.   *
Attentiveness
Attention Span: *
Distractible: *
Alertness:  *
Response Rate:  *
Awareness of Environmental Events: *
Cooperation: *
Receptive Language
Oral Comprehension: *
Required
Understands Basic Concepts: *
Required
Concepts Understood: *
Required
Responds to Name:  *
Responds to Attention Commands (e.g., No, Stop, Listen, etc.)  *
Looks at Pictures:  *
Required
Routine Commands:  *
Required
Nonverbal Comprehension: *
Required
Two-Dimensional Recognition  *
Required
Expressive Language
Verbal Status:  *
Expressive Level:  *
Methods of Communication:  *
Required
Self Expression:  *
Required
Operates Cause and Effect Item:  *
Required
Vocabulary:  *
Required
Pragmatic/Social Language 
Communication Intent  *
Required
Initiates Communication: *
Answers "Wh" (Who, What, Where) Questions:  *
Answers "When, Why, and How" Questions:  *
Answers "Yes/No" Questions:  *
Ask Questions:  *
Conversational Topics:  *
Required
Turn-Taking:  *
Topic Initiation:  *
Reading/Literacy: *
Required
Writing/Spelling: *
Required
Speech 
Understood By:   *
Required
Adjusts Speech to Improve Understanding:  *
Sounds Produced:  *
Required
Dentition:  *
Required
Oral Motor Imitation:  *
Voice 
Loudness (Volume)  *
Voice Quality *
Oral  
Drooling  *
Tongue Thrust  *
Swallowing and Diet *
Required
Fluency
Fluency:  *
Rate of Speech:  *
Non-Oral Communication  
Use of Sign Language:  *
Required
Sample Signs:  *
Express Yes/No:   *
Required
Fine Motor Abilities *
Parental Concerns  
Please provide any concerns that the parents/guardians have addressed in regards to the child's communication.   *
Summary
Results of Tests/Assessments:   *
Current Communication Goals/Objectives:  *
Communication Strengths:  *
Communication Limitations:  *
Interventions/Strategies that you have already attempted/implemented:  *
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