Easter Seals



-171450-31623000Easter SealsAUGMENTATIVE COMMUNICATION INTAKE INFORMATION FORMSchool-Based ServicesDate: FORMTEXT ????? IDENTIFYING INFORMATION Student Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????Age: FORMTEXT ?????Address: FORMTEXT ?????Parents/Guardians: FORMTEXT ?????Telephone:Home: FORMTEXT ?????Cell: FORMTEXT ?????Email FORMTEXT ?????Person(s) filling out form: FORMTEXT ?????Relationship to student: FORMTEXT ?????Daytime phone: FORMTEXT ?????Email: FORMTEXT ?????SCHOOL INFORMATION:Name of School: FORMTEXT ?????Address: FORMTEXT ?????School Contact Name: FORMTEXT ?????Best way to reach the school contact: FORMCHECKBOX phone FORMCHECKBOX email FORMTEXT ?????PURPOSE OF VISITWhat answers do you hope to gain from this referral/assessment? FORMTEXT ?????MEDICAL DIAGNOSIS FORMTEXT ?????VISION AND HEARINGDescribe any visual concerns: FORMTEXT ?????Describe any hearing concerns: FORMTEXT ?????Does the student wear glasses? FORMTEXT ?????Date of most recent hearing exam: FORMTEXT ?????Date of most recent vision exam: FORMTEXT ?????Reason? FORMTEXT ?????COMMUNICATIONWhich of the following does the student use to communicate? Please check all that apply: FORMCHECKBOX Eye contact FORMCHECKBOX Gestures, Pointing FORMCHECKBOX Picture symbols FORMCHECKBOX Eye pointing FORMCHECKBOX Pulling person to desired object FORMCHECKBOX Single words FORMCHECKBOX Facial expressions FORMCHECKBOX Sign language FORMCHECKBOX Communication boards/book FORMCHECKBOX Vocalizations FORMCHECKBOX Photographs FORMCHECKBOX Spoken words FORMCHECKBOX Two word combinations FORMCHECKBOX Complete sentences FORMCHECKBOX Communication device FORMCHECKBOX Short phrases FORMCHECKBOX Write or type FORMCHECKBOX Other (please specify)Other: FORMTEXT ?????Does the student (please check all that apply)? FORMCHECKBOX Initiate communication? FORMCHECKBOX Understand simple instructions? FORMCHECKBOX Respond to speakers? FORMCHECKBOX Understand what is said in conversation?Voice Output CommunicationOutput CommunicationIf the student is using an Augmentative Communication Device, please answer the following:Type of device: FORMTEXT ?????How old is the device? FORMTEXT ?????Funding source for the device? FORMTEXT ?????Is the student currently using the device? FORMTEXT ?????Is the student using a mobile device such as an iPad? If yes, please choose type of tablet below. FORMTEXT ?????Type of tablet FORMCHECKBOX iPad FORMCHECKBOX iPad Mini FORMCHECKBOX Android tablet FORMCHECKBOX Other FORMTEXT ?????What apps are currently being used? FORMTEXT ?????Does the student use voice output communication to: FORMCHECKBOX Express wants and needs FORMCHECKBOX Greet people FORMCHECKBOX Ask questions FORMCHECKBOX Make Comments FORMCHECKBOX Label objects, people, pictures FORMCHECKBOX Ask for help FORMCHECKBOX Share informationFINE AND GROSS MOTOR INFORMATIONGross Motor Status: FORMCHECKBOX Walks independently FORMCHECKBOX Unable to walk FORMCHECKBOX Walks independently but needs supervision FORMCHECKBOX Independent with manual wheelchair FORMCHECKBOX Walks independently but with assistive device such as walker FORMCHECKBOX Requires assistance with manual wheelchair FORMCHECKBOX Able to walk for short distances FORMCHECKBOX Independently controls power wheelchairHow does the student control the power wheelchair? FORMTEXT ?????Fine Motor Status: FORMCHECKBOX No concerns FORMCHECKBOX Has difficulty using both hands FORMCHECKBOX Right hand dominant FORMCHECKBOX Uses hand to point to targets 1x1” or smaller FORMCHECKBOX Left hand dominant FORMCHECKBOX Uses hand to point to targets 1x1” or largerThe student can most easily control movements with: FORMCHECKBOX Eyes FORMCHECKBOX Left hand FORMCHECKBOX Head FORMCHECKBOX Foot FORMCHECKBOX Right hand FORMCHECKBOX OtherOther (please specify): FORMTEXT ?????ADDITIONAL INFORMATION OR CONCERNS: FORMTEXT ?????PLEASE ATTACH ANY RELEVANT REPORTS WITH INFORMATION RELATING TO COMMUNICATION, COGNITION, OR OVERALL DEVELOPMENTAL LEVEL.Thank you for returning the form:atintakes@Easter Seals, 484 Main Street, 6th Floor, Worcester, MA 01608Attention: AT IntakesPlease direct any questions to Kristi Peak-Oliveira, Clinical Supervisor, at kpoliveira@ or 617-226-2861 ................
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