IDENTIFYING INFORMATION
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Referred by Name
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Address
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Phone
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Home Contact Name
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Address
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Phone
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School/Agency Name
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Address
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Phone
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Contact Person School/Agency
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Address
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Phone
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Physician Name
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Address
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Phone
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Person(s) filling out form:
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Brief description of communication problem:
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Primary language spoken at home:
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MEDICAL/SENSORY INFORMATION
Medical Condition/Diagnosis:
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Onset:
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Seizures (Yes/No):
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Describe any visual problems:
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Date of most recent vision exam:
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Does he/she wear glasses? :
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Describe any hearing problems:
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Date of most recent audiological exam:
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Is there a history of middle ear infections? :
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Tubes ever inserted? :
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Additional medical/sensory information or comments:
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GROSS/FINE MOTOR SKILLS:
Ambulates? :
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Assisted? :
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With what equipment/assistance? :
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Power or manual chair? (If both, please describe when/where each used):
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What changes in wheelchair seating are planned in the next year? :
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Can he/she write or draw? Please describe:
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Can he/she use a hand to point? Please describe (e.g., uses one finger, uses whole fist, etc.) If possible, please also describe the target size (e.g., picture size, etc.), spacing between target, and size of field necessary for effective pointing:
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Can he/she use some sort of pointer to point? Please describe (e.g., head stick, light pointer, hand held pointer, etc.) If, possible, please also describe the target size (e.g., picture size, etc.), spacing between targets, and size of field necessary for effective pointing:
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Does he/she use eye gaze to point? If possible, please describe the target size (e.g., picture size, etc.), spacing between targets, and size of field necessary for effective eye pointing:
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Is he/she able to use either a standard or adapted keyboard to access a computer? Please describe:
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Does he/she use a switch/switches to access toys, appliances, a computer, etc.? Please describe switch placement and the devices used. [If accesses computer, describe level of proficiency: cause & effect, scanning (# of locations?), etc.]:
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RECEPTIVE LANGUAGE SKILLS
Does he/she understand the speech of others?
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Does he/she follow directions with gestural assistance or contextual cues?
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Results of formal receptive language tests (Please give the name of the test, date given, and approximate developmental level obtained):
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Results of informal receptive language test (e.g., developmental scales or observations):
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COGNITIVE/ACADEMIC INFORMATION
Does he/she have any spelling skills? On what grade level?
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Does he/she have any reading skills? On what grade level?
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FOR THOSE WITH LIMITED OR NO READING SKILLS:
Does he/she have categorization skills?:
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Circle items he/she can identify (by pointing to or looking at) when named:
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Circle items he/she can match to objects:
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Photos
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Color pictures
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Bl.&wh. Line drawings
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What size photos/pictures/drawings are required for successful identification or matching?:
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DAYTIME SETTING
Preschool:
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Integrated Preschool:
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Substantially separate classroom:
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Substantially separate classroom w/integration for certain activities (please specify):
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Day habilitation or adult day care program:
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Supported employment (please specify):
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Regular employment (please specify):
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EXPRESSIVE COMMUNICATION SKILLS:
Does he/she speak in words at times? Are these words understandable to unfamiliar listeners? :
Does he/she use manual signs to communicate? Please estimate the number of signs used (if under 10, please list). Does he/she combine 2 or more signs to communicate (please describe)? :
Does he/she use any type of non-electronic communication device (e.g., communication board, mini- boards, notebook, etc.)? Please describe the device and symbol system (e.g., pictures, sight words, etc.) Does he/she combine 2 or more symbols to communicate (please describe)? :
Does he/she use any type of electronic communication device? Please describe:
Are the above communication systems used outside of therapy? Please describe:
Please describe any previously unsuccessful augmentative communication systems:
Does he/she initiate communication? If so, please describe how and in what situations:
How does he/she make wants/needs known (or how do you figure out his/her wants/needs)? In what situations? :
Does he/she share information (e.g., communicate about events, feelings, etc.)? Please give some examples:
Does he/she have ways to maintain a social interaction (e.g., either through conversation using signs, pictures, etc. or else via turn – taking routines such as clapping and smiling, ect.) Please give some examples:
How does he/she communicate “yes” and “no”? Is the yes/no response accurate?
Does he/she get frustrated when unable to communicate effectively? If so, please describe:
Results of formal expressive language tests (Please give the name of the test, date given, and approximate developmental level obtained):
Results of informal expressive language tests (e.g., developmental scales or observations):
MISCELLANEOUS
What are his/ her speech – language therapy goals? (may enclose portion of IEP or ISP ):
What are his/her future educational/vocational plans? :
What experience has the person had with computers or technology in general? :
List professions from whom he/she is currently receiving services:
Name
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Type of Therapy or Instruction
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What specific questions would you like addressed in this evaluation/consultation?
What further information do you wish to obtain from this evaluation/consultation?
PLEASE ATTACH ANY RELEVANT REPORTS WITH INFORMATION RELATING TO COMMUNICATION, COGNITION, OR OVERALL DEVELOPMENTAL LEVEL.
Thank you for returning this form to the Easter Seals Massachusetts as soon as possible.
Please mail to:
Easter Seals of Massachusetts
Attn: Jeff McAuslin
484 Main Street, 6th Floor
Worcester, MA 01608
508-751-6448
jmcauslin@eastersealsma.org
Fax: 508-831-9768
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