KM CAT Assessment Form

Referrer Acknowledgement

• You are referring for an assessment as a Health, Education or Social Care Professional.
• If you are an Independent Therapist you are confident that you are eligible to make this referral (please see the guidance on who can refer on our website).
• You have read the NHSE criteria for Specialised AAC Services and are confident that your patient meets this.
• By submitting the referral, you have agreed to our joint working model. This includes developing strategies and resources for low-tech AAC with the patient, involvement in the whole process of our assessment, training, provision, follow ups and ongoing support to the patient and their network of support.

Please tick to acknowledge that you have read and agreed to the above.

Consent to referral

Has the patient consented to this referral? ^*

Yes Best interest decision No

Please note: We will not be able to accept this referral without consent or a best-interests decision

If a best interest decision please send a copy of the MCA day to day decisions form and explain why this referral is in best interests

Referrer Information

Referrer's Name ^*

Referrer's Role ^*

Referrer's Address ^*

Referrer's Telephone Number ^*

Referrer's Email Address ^*

Patient Information

Patient's Title ^*

Patient's Name ^*

Patient's Preferred Name

Patient's Date of Birth ^*

Day

Month

Year

Patient's NHS Number ^*

Patient's Gender ^*

Patient's Pronouns

Patient's Ethnicity ^*

Patient's Diagnosis ^*

Patient's Date of Diagnosis ^*

Patient's Allergies ^*

Patient's Other Significant Medical History ^*

Does the Patient have diagnosis of Epilepsy or any condition which may impact the use of a screen-based device? ^*

Yes No

Please provide more details

Does the patient have a valid in date DNA CPR? ^*

Yes No Unsure

Patient's Medication e.g. opiates, sedatives, muscle relaxants, epilepsy medication ^*

Patient's Home Address ^*

Is this where they are currently residing? ^*

Yes No

Please provide details of where there are currently residing, including contact details

Patient's Telephone Number ^*

Patient's Email Address

Patient's Preferred Contact Method ^*

Telephone Number Email Address

Patient's GP Name and Address ^*

Details of other people involved

Next of Kin - Name ^*

Next of Kin - Relationship ^*

Next of Kin - Telephone Number ^*

Next of Kin - Email Address

Next of Kin - Home Address ^*

Key person supporting patient with AAC - Name ^*

Key person supporting patient with AAC - Relationship to Patient ^*

Key person supporting patient with AAC - Telephone Number ^*

Add 2nd Key Person supporting patient with AAC

2nd Key person supporting patient with AAC - Name

2nd Key person supporting patient with AAC - Relationship to Patient

2nd Key person supporting patient with AAC - Telephone Number

Speech and Language Therapist - Name

Speech and Language Therapist - Contact Details

Occupational Therapist - Name

Occupational Therapist - Contact Details

Other party - Name

Other party - Role

Other party - Contact Details

Who is the best person to contact to organise the assessment? ^*

To your knowledge are there any health and safety/safeguarding issues that we need to be aware of? ^*

Yes No

Please let us know if you would prefer to discuss this and we will contact you

Is the patient currently working? ^*

Yes No

Please provide details of the patient's current work

NHS England Criteria

Please describe and give examples as to how the person meets the NHS England criteria.

If the answer to any of the questions below is 'No' then the person does not currently meet the eligibility criteria for complex AAC assessment. Please note, this does not necessarily mean that the person should not have access to AAC or other technology. It means that they are not suitable for assessment and provision under this service specification at this time. Other support and funding streams may be more suitable.

Has the person developed beyond cause and effect understanding? ^*

Yes No

Please describe and give examples

Is the person able to understand the purpose of a communication aid? ^*

Yes No

Please describe and give examples

Is there a clear and evidenced discrepancy between the person’s level of linguistic understanding and their ability to use biological speech? ^*

Yes No

Please describe and give examples

Does the person have experience of using low-tech AAC and are there reasons why it is insufficient to meet their communication needs?

Yes No

Please describe and give examples

How is the person likely to use high-tech or low-tech AAC in terms of language competence? ^*

Unlikely to be able to combine words, phrases or symbols to create more than one concept. Uses high tech aids or low-tech systems to select one concept at a time.

Likely to be able to use complex multi-page vocabulary to combine multiple words, phrases or symbols to compile a message.

Likely to be able to construct novel messages using the alphabet.

The person is unable to select items on a touchscreen or keyboard with sufficient speed and endurance to meet their reasonable communication needs.

Yes - Person is unable to use keyboard/touchscreen No - Person is able to use keyboard/touchscreen

The person is unable to select items on a touchscreen or keyboard with sufficient speed and endurance to meet their reasonable communication needs or is expected to require alternative access within the next 18 weeks.

Yes - Person unable to use keyboard/touchscreen No - Person is able to use keyboard/touchscreen

Please provide examples of how the person is using AAC, including evidenced examples of how this has enabled them to convey a range of communicative functions? ^*

Expectations

What do you expect from this referral? ^*

Is this a priority referral? ^*

Yes No

Please explain why this is a priority referral

Abilities

Does the patient have any cognitive difficulties? ^*

Yes No Unsure

e.g. attention, problem solving, memory

Please describe the patient's cognitive difficulties

Are there any psychological factors to be considered? ^*

Yes No Unsure

e.g. motivation, mental-health, well-being or behaviour

Please describe the patient's psychological factors to be considered

Do they have any eye-movement difficulties, visual impairment or visual perceptual difficulties? ^*

Yes No Unsure

e.g. reduced eye-movement, blurred vision, double vision, needs large font

Please describe the patient's visual difficulties

Please comment on the patient’s physical abilities and voluntary movement in the following areas; including range of movement.

Head ^*

Upper limbs ^*

Lower limbs ^*

How does the patient move around - both inside and outside? ^*

Where does the patient spend most of their time? ^*

e.g. bed, wheelchair, comfy chair

Daily routine and support

What is the patient's social situation? ^*

e.g. Who do they live with? What is their care package?

What is the patient's daily routine? ^*

What support is available to the patient in regards to the development, training and use of their communication aid? ^*

Communication

Please describe how the patient indicates yes and no ^*

Please describe the patient’s speech ^*

e.g. quality, intelligibility, endurance

How does the patient currently communicate, including details of what communication aids are being used ^*

Please forward copies/photos to acat.service@nhs.net

Describe the patient’s receptive language skills - include details of any standardised or informal assessments ^*

Describe the patient’s expressive language skills - include details of any standardised or informal assessments ^*

Please give details of the patient’s current literacy skills ^*

e.g. patient was literate but now struggles to spell out

Additional Information

Is there anything else you wish to add?