Name:	Date of Birth:
Site:	SSID:
Class Days/Times:
Service Coordinator:	SLP:
Other IFSP Team Members:
Referral initiated by: Team Family
Person(s) Completing Referral:	Date Submitted:
Date Parents informed of referral by service coordinator: Parent contact documented in the contact log? Yes No
Coordinator Signature:	Date:
Director Signature:	Date:

EI/ECSE Referral for Augmentative Communication:

Please complete the following form for the student you are referring. All sections need to be completed.

Thank you!

(*If the child has a privately owned AAC device and you are requesting consultation what is the name of the device owned: )

Requesting: Consultation	Comprehensive Assessment

Is the student also receiving an AAC Assessment through an outside provider?

No Yes Provider: Location:

Are there concerns about:

Vision: No Yes	Hearing: No Yes	Fine Motor: No Yes

Gross Motor: No Yes

During Free Play, the child enjoys:

Please describe how the child interacts with preferred toys:

If the child is verbal:

Familiar listeners (teacher, assistants) understand: % of speech

Unfamiliar listeners (substitutes, related svc. providers) understand: % of speech

Primary caregivers understand % of speech

The child’s present means of communication include: (check all that apply)

Changes in breathing patterns or body posture

Pointing or gestures

Single words

Eye-gaze/eye movement

Non-speech vocalizations

Sign Language (# signs )

Verbalizations

Voice output device:

Other:

How does the child respond when…

(please be concise)

Play is interrupted:

Path is blocked:

Name is called:

There is a change in routine:

Asked a yes/no question:

Asked a wh- question:

Given a familiar/routine 2-step direction:

Given a novel 2-step direction:

Is there any other information that is important for the AAC Specialist to be aware of prior to initiating contact?

Send completed form to Coordinator.