KM CAT Consultation Form

Referrer Acknowledgement

You are referring for a consultation. This service is for local therapists who have a patient with a communication difficulty and you are unsure how to proceed. The team will meet with you (the local therapist) and any relevant colleagues. Please note the patient or their family/carers do not attend.

You, the referrer, maintain duty of care and responsibility for decision-making.

Please tick to acknowledge that you have read and agree 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 to acat.service@nhs.net and explain why this referral is in the Patient's best interest

Referrer details

Referrer's Name ^*

Referrer's Role ^*

Referrer's Address ^*

Referrer's Telephone ^*

Referrer's Email ^*

Personal Information of patient to be discussed

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 Other Significant Medical History ^*

Patient's Home Address ^*

Is the above address where the Patient is currently residing? ^*

Yes No

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

Patient's Telephone Number ^*

Patient's GP Name and Address ^*

Details of other people involved

Please provide details of other relevant professionals involved. Please include their contact details if they also plan to attend the consultation

Expectations

What do you expect from this referral? ^*

e.g. do you require advice on assessment, resources, app selection, whether a patient meets the NHSE criteria etc.

Abilities

Please fill in the sections below that are relevant to your consultation goals. You only need to fill in what you know about the patient.

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 a communication aid? ^*

Communication

Describe how the patient indicates yes and no ^*

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

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?