Date referral received at ACS:
Assistive Communication Service
South Westminster Centre for Health
St Georges House
82 Vincent Square
London
SW1P 2PF
TEL: 0208 1024067
INFORMATION FOR CHILD ASSESSMENT
PLEASE COMPLETE AND RETURN TO THE ACS AT THE ABOVE ADDRESS
Fields marked with * are mandatory and therefore must be completed. Please note that we are
unable to process this referral in the absence of their completion!
* School Name:
* Full Name:
* School Address:
* Date of Birth:
*Gender
* Postcode:
* Address:
* Tel. No.:
* Class Teacher Name:
* Postcode:
* Tel:
* SENCO Name:
* Childs NHS number:
* Is a Speech and Language Therapist involved
* GP Name:
with this child?
Yes
* GP Address:
No
If so, what is the name, address and number of
the speech therapist involved?
* Name:
* Postcode:
* Address:
* GP Tel. No.:
* nhs.net email:
* Name of Referrer:
*Telephone No.:
* Relationship to Child:
* Is the Speech and Language Therapist aware
* Referrer Address:
of the referral?
Yes
No
* Postcode:
Allergies and Sensitivities:
* Telephone No:
Yes
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No
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 Assistive Communication Service
The Assistive Communication Service is a service provided by Central London Community Healthcare NHS Trust
* CONSENT
Have the aims and intentions of this assessment, as far as possible, been fully and realistically explained to the
child and their family/carers?
* PURPOSE OF REFERRAL (what questions would you like the service to answer?)
* MEDICAL DIAGNOSIS: (including onset)
COMMUNICATION:
WHAT ARE THE MAIN DIFFICULTIES?
HOW DOES THE CHILD COMMUNICATE CURRENTLY?
HAVE COMMUNICATION AIDS BEEN USED IN THE PAST?
HAVE ANY FORMAL ASSESSMENTS OF LANGUAGE BEEN USED?
(a) Receptive Language and results:
(b) Expressive Language and results:
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SENSORY FACTORS:
(a) Hearing:
(b) Vision:
(c) Sensation:
INTELLECTUAL/COGNITIVE FACTORS:
(a) Perceptual skills:
(b) Matching ability:
(c) Recognition of symbols/ability to read letters/words:
(d) Spelling ability:
(e) Long/short term memory:
(f) Concentration/attention:
PHYSICAL FACTORS:
ARE THERE ANY PHYSICAL DIFFICULTIES?
PLEASE DESCRIBE THE CHILD’s MOST RELIABLE MOTOR SKILLS:
(i.e. raising an arm, pointing, eye gaze, turning head etc)
NB. Any supports, splints or switches which facilitate these skills should be brought to the assessment.
HAS SEATING/POSITIONING BEEN INVESTIGATED OR ASSESSED? (please summarise outcome)
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1.
ENVIRONMENTAL NEEDS:
PLEASE OUTLINE THE CHILD’s ACTIVITIES AND SITUATIONS IN A “TYPICAL” DAY:
2.
SUPPORT
How much time would be available in the child’s environment to support development and training with
respect to any technology recommended following assessment?
3.
FUNDING
What consideration has been made regarding funding for the provision of any technology recommended?
4.
DEMOGRAPHIC QUESTIONS:
We constantly monitor the service we offer and would be grateful if you would answer the following
questions relating to Ethnic Origin/Marital Status and Employment Status.
Religion:
* Ethnic Origin:
5.
ANY OTHER INFORMATION WHICH YOU FEEL WE SHOULD HAVE?
6.
ANY DATES, DAYS OR TIMES THAT YOU KNOW YOU CANNOT ATTEND?
7.
THIS WILL BE A CHILD/FOCUSED APPOINTMENT. INDIVIDUALS WHO MAY HAVE
DIRECT INPUT TO THE EVALUATION ARE INVITED TO ATTEND (Please list those
individuals who wish to attend on the day. Please keep this to a minimum)
NAME and PROFESSION OF REFERRER:
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