South East Consortium for Special Education 3434 Marten Ave. San Jose, ca 95148 Phone: 408. 223. 3771 / Fax: 408. 532. 9311

South East Consortium for Special Education

3434 Marten Ave.

San Jose, CA 95148

Phone: 408.223.3771 / Fax: 408.532.9311

Augmentative Communication Solutions Group is available to complete Augmentative/Alternative Communication (AAC) assessments as well as Assistive Technology (AT) Assessments for school districts. In order to efficiently facilitate the evaluation and conduct it in a comprehensive manner, we kindly ask that a district staff member this complete the form. The Special Education Director must sign the document to indicate approval.

Does school district authorize an on-site observation of the student ☐Yes ☐No

If Yes, contact person to arrange observation: Click here to enter text.

Phone/email of contact person: Click here to enter text.

☐Articulation/speech intelligibility ☐Oral-motor skills ☐Fluency ☐Vocabulary/semantics

☐Voice (volume, pitch, quality) ☐ Social-pragmatics ☐Grammar/syntax

COMMUNICATION METHOD:

What method of communication is the child currently using?

☐ Verbalization/Vocalization ☐ Eye Gaze ☐ Facial Expressions ☐Pictures/PECS

☐Gestures/Signs ☐AAC Device/App- If so, device(s) used: Click here to enter text.

☐Other: Click here to enter text.

ADDITIONAL INFORMATION WE SHOULD KNOW ABOUT THE STUDENT: Click here to enter text.

PLEASE NOTE: As independent assessors, we may find areas of deficit/delay that do not meet eligibility criteria under Special Education codes. We reserve the right to inform parents/advocates of such areas as a result of our testing with the understanding that the information will be shared with the IEP team.
Please note the following documentation must be attached to begin the referral process:

• 
  Completed SELPA Augmentative and Alternative Communication Assessments (AAC) form
  
• 
  Evaluation Reports (Psycho-Ed., Speech, OT, etc.) from the PAST TWO YEARS, and current/subsequent IEP including IEP meeting notes.
  
• 
  Signed and dated Assessment Plan for AAC Assessment (Assessment Plan is not required for Independent Educational Evaluations.)
  
• 
  Signed Authorization Exchange of Student Health and Educational Information
  

______________________________________ Click here to enter text.