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About Us
Our Leadership
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Services
Children’s Services
Infant and Toddler Program
Preschool Program
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Adult Services
Community Participation Supports
Behavioral Support
Communication Services
Home and Community Supports
Residential Services
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TRAIL Academy
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Apply Now
Center for Training and Professional Development
Aspire Foundation
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Augmentative and Alternative Communication Evaluation Request
Individual’s Name
Date of Referral
MM slash DD slash YYYY
Date of Birth
MM slash DD slash YYYY
Gender
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
Current Living Situation
Current Living Situation
Community Living Arrangement
Family Residence
Residential Agency
Contact Name/Title
Contact Phone
Contact Email Address
Secondary Contact Name/Title
Secondary Contact Phone
Supports Coordinator
Supports Coordinator Phone
Supports Coordinator Email
Supports Coordinator Agency
Vocational/Day Program Information
Work/Program Agency
Contact Name/Title
Vocational/Day Program Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Vocational/Day Program Phone
Vocational/Day Program Email
Job/Activities Performed
Reason for Referral
Person Making Referral
Relationship to Individual
Referral Phone
Referral Email
Additional Referral Information
New Referral
Updated Evaluation
Change in behavior
Recent change in communication status
Change in level of functioning
Family or advocate request
Past history of device use
Currently using device or other communication system
Please List Devices
Communication Information
Medical/Speech Diagnoses
Adaptive Devices
Last Hearing Test & Results
Last Vision Test & Results
Does the individual have the ability to push a button?
Yes
No
Does the individual have the ability to use a tablet/computer?
Yes
No
Does the individual have the ability to manipulate an object?
Yes
No
Does the individual have the ability to use a keyboard?
Yes
No
Does the individual have the ability to talk on the phone?
Yes
No
Does the individual have the ability to understand complex instructions?
Yes
No
Does the individual have the ability to move their head side to side?
Yes
No
Does the individual have the ability to track an object with their eyes?
Yes
No
Are they literate?
Yes
No
Does the individual have the ability to choose between 2 objects/pictures?
Yes
No
Additional Information About Abilities
Communication Information
How does the individual currently communicate? (check all that apply)
Words
Signs
Gestures
Pictures
Sounds
Behavior
Facial Expressions
Writes/Types
Other
What are the most important communication needs at home?
What are the most important communication needs at work/day program?
What has been attempted to increase effective communication in the past?
Does the individual exhibit any concerning behaviors?
Does the individual have a Behavior Support Plan?
What are the individual’s preferred activities?
What are the individual’s preferred foods?
What are items/objects that the individual prefers?
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