HAltComms Needs Assessment Form

Holistic Alternative Communication Services
Needs Assessment Form

(d)eaf/Hard-of-Hearing or Persons Requiring Alternative Communication
Date

MonthDayYear
Date
Client is
Developing an Individualized Assisted Communication Support System.

1The Service Provider/Host must also consider the following special factors when applicable[A}in the case of a client who is deaf or hard of hearing or who is deaf-blind, the Client’s(A) language and communication needs;(B) opportunities for direct communications with peers and professional personnel in the Client language and communication mode;(C) academic level; and(D) full range of needs including opportunities for direct instruction in the client’s language and communication mode.
Client Language and Communication Needs

Receptive and Expressive Communication Continuums
The Client uses one or more of the below, check all that apply
The Client primarily comprehends/uses /prefers one or more of the following formsof communication in the various contexts (check all that apply and add notes to clarify if needed):

The Below may be adopted for Physical Scenarios(Meetings, Lifestyle Appointments etc)
Communication Type in The Home/With deaf Peers/Social Scenarios[Receptive]
Communication Type In The Work Place/Formal Scenarios[Receptive]
Communication Type In The Home/With Peers/ Social Scenarios[Expressive]
Communication Type In The Work Place/Formal Scenarios[Expressive]
Meetings Continuum

Mainly For Virtual Scenarios

Tick most preferred platform

Rows	LIFESTYLE(Medical,Police,Interviews,Legal,General)	WORK(With Management)	WORK(With Colleagues)	WORK EVENTS
ZOOM
GOOGLE MEET
MICROSOFT TEAMS
SYKPE
WHATSAPP VIDEO
FACEBOOK ROOMS/LIVE
GOOGLE HANGOUT
SLACK
OTHER

Needs Assessment Form