Paediatric
Communication
Aids Service

Claremont School, Henleaze Park Westbury-on-Trym, Bristol BS9 4LR
Tel: (0117) 924 7527
Fax: (0117) 942 6942 

 
                                              Ref:SC/mjp/Refquest

                                              Date: 

REFERRAL QUESTIONAIRE 

NAME:                                     Date of Birth

Address:                                  Tel No:



                                          Postcode:  

Pre-school/School:



Parents(s) Name:

Referred by:

GP:               Consultant Paediatrician

Speech and Language Therapy Diagnosis:





Associated Problems:
(vision, hearing,
learning difficulties)








A.    COMMUNICATION

1.     What are the child's current means of communication? please
       tick as appropriate: 

            vocalisations
            speech
            eye-pointing
            signing
            low tech system (symbol book)
            high tech communication aid
            other

2.     Has the child ever been assessed for a communication aid?

3.     Has the child used a communication aid in the past, and if so
       with what results? 


B.     PHYSICAL SKILLS

1.     Is the child independently mobile, or does he/she use
       a wheelchair?


2.     How does the child sit? Please tick as appropriate:

       - conventional seat
       - box seat
       - supportive seat
       - wheel chair - powered
                     - manual
       - other 


3.     Describe the childs level of hand function.
       Please tick as appropriate:

       - within normal range for age
       - minimal disability
       - restricted range of movement
       - no range of movement

4.     Is the child able to finger/fist point or is the child 
       a switch user?

     


C.     SWITCHES


1.     do you require advice on the most appropriate switch usage
       for the child?
       (type of switch, positioning)?


2.     If a switch is currently being used, please describe:




3.     Does the child have access to a computer at school/home?



4.     Is the child known to an Occupational Therapist?
       If Yes, please name the therapist:



D.     COGNITIVE SKILLS


1.     What is the childs level of verbal undestanding?




2.     If appropriate, please describe the child's
       reading/spelling skills



3.     If appropriate, please describe the child's use of 
       symbols.


E.     ASSESSMENT

1.     Referring to the different levels of assessment (levels 1-4)
       which level are you requesting?


2.     Has funding for this assessment service been agreed,
       and if so by whom?





Any other comments:











Please return this questionaire to:-

       Sally Chan, Speech and Language Therapist
       Claremont School, Henleaze Park,
       Henleaze, BRISTOL BS9 4LR