KM CAT Provision-Only Referral Form

Referrer Acknowledgement

Our provision-only service is available to therapists for patients registered to a GP in East Kent (including Ashford) or Swale (including Sittingbourne, Sheppey, Teynham, and Newington).

When requesting equipment or apps, KMCAT act as an equipment library only; the referrer maintains responsibility for the patient’s duty of care. This includes:

collection/return of equipment when it is no longer needed.

providing training/support/technical advice when needed;

KMCAT can repair/replace hardware but are not here to provide technical support e.g. setting up accounts, installing or updating apps. Referrers will be expected to provide this support to their patients and to liaise with the relevant companies as needed.

The Apple ID email account you give us on this form will be the one we gift the app to. We are unable to regift the app. Ensure that this is the correct email address that is associated with the patient’s Apple ID account.

If your patient wishes to use an app on an Android device, please contact us to discuss options before making a referral.

Please 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 to acat.service@nhs.net and explain why this referral is in best interest

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 Other Significant Medical History ^*

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

Preferred contact method ^*

Telephone Email

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 - Address ^*

Key person supporting patient with AAC - Name ^*

Key person supporting patient with AAC - Relationship with 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 with Patient

2nd Key person supporting patient with AAC - Telephone Number

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

Yes No

If Yes, please let us know if you would prefer to discuss this and we will contact you.

Is the patient currently working?

Yes No

If Yes, please give details

Expectations

What do you expect from this referral? ^*

Is this a priority referral? ^*

Yes No

Please explain why this is a priority referral

Equipment/App Request

What AAC options have you considered? ^*

What equipment/app are you requesting? Please include details of any standard accessories e.g. stylus, Lightwriter keyguards. ^*

Please state your clinical reasoning for choosing this equipment and/or app ^*

Have they had any experience with the equipment/app you are requesting? ^*

If the equipment you are requesting is keyboard based, please select the appropriate keyboard layout option ^*

QWERTY ABC N/A

If your request is for an app please provide the patient’s email address for their Apple ID (please write N/A if not requesting an app) ^*

What is the plan for support for the day-to-day use of the equipment/app e.g. charging, app-backup, set-up? ^*

What low-tech AAC will be provided as a backup? ^*

Additional Information

Is there anything you wish to add?