AAC Interest Form 2023

AAC Interest Form 2023
Name of Caregiver

First NameLast Name
Email
example@example.com
Relationship with child using AAC
Phone Number
Please enter a valid phone number.Format: 0000-0000.
Name of Child

First NameLast Name
Age of Child
Diagnosis of Child
YesNo
3. We would like to know more about your child.
NoYes
Describe how does the individual answer yes/no question.
Who best understands the individual and why?
a. Understand directions/commandsb. Makes choicesc. Express general ideas.
NoYes
If yes, describe.
All the timeSome of the timeSeldomNever
IndependentlyWith some prompts or support from communication partnerWith heavy support from communication partnersOnly when prompted buy communication partners
Note: Please bring along any existing communication devices/books during intake meeting.
What activities/items/interests does the individual like/have?
How would you describe the individual's general physical abilities and/or behavioural changes?
9. Does the individual have
NoYes
Describe
NoYes
Describe
NoYes
Describe
NoYes
Describe
NoYes
Describe
Please bring spectacles/hearing aids/lap tray for the meeting. (if applicable)
HeadArmFingersElbowFootToeFistEyeOther
Should be Empty: