Herb and Joanne Hein, Speech-Language Pathologists Hein Speech-Language Pathology, Inc.
AAC Evaluation Tools - The Georgia Speech-Language Hearing ...€¦ · 2. Speech and Language...
Transcript of AAC Evaluation Tools - The Georgia Speech-Language Hearing ...€¦ · 2. Speech and Language...
AAC Evaluation
Tools
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Dynamic AAC Evaluation Protocol
Step I: Initial Client Information Form
Client Info: Personal
Client Name: DOB:
Social Security Number: Gender:
Date of Onset: Date of Current Plan of Treatment:
Student: yes no
Name of School:
Grade:
Employed: yes no Name of Employer:
Medicare # Medicaid #
Managed Care Medicaid yes no Managed Care Medicaid ID#
Does client currently own a communication device:
yes no
Make and Model:
Date of Purchase:
Client Info: Residence
Place of Residence:
Home Facility
If Facility, Name:
Facility Main Phone:
Address:
Home Phone: County:
Alternate Phone:
Email:
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Client Info: Medical Diagnosis
Medical Diagnosis:
ICD-9 Code:
Speech Diagnosis:
ICD-9 Code:
Date of Onset, Accident, or Diagnosis:
Type of Accident:
Employment Auto Other
Date of Evaluation:
Client Info: Family Contact/Legal Guardian Use Client Address Info
Contact Name: Relationship to Client:
Contact Home Phone: Address:
Contact Alternate Phone:
Contact Email:
Contact Fax:
Client Info: Treating Physician
Physician Name: Physician Address:
Physician Phone:
Physician Fax:
Physician Email:
Medicaid Provider # Physician UPIN
Physician NPI # Physician License #
Medicaid Primary Care Physician Name
Medicaid Primary Care Physician Phone
Client Info: Private Insurance Use Client Address Info
Name of Insurance Company:
Address:
Employer Name:
Policy # Group #
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Policy Holder Name: Case Manager:
Policy Holder SS# Policy Holder Relationship to Client
self spouse parent legal guardian Policy Holder Date of Birth:
Client Info: Other Insurance
Use Client Address Info
Name of Insurance Company:
Address:
Employer Name:
Policy # Group #
Policy Holder Name: Case Manager:
Policy Holder SS# Policy Holder Relationship to Client
self spouse parent legal guardian Policy Holder Date of Birth:
Client Info: Alternate Funding-
Please list and describe in detail any alternate funding sources
Prescription from Primary Physician
Copies of ALL insurance and Medicaid/Medicare cards, front/back
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Statement of Problem: Please explain the concerns which brought you to this office
Desired Outcome of Treatment: What would you like to happen as a result of today’s visit and our subsequent involvement with your family?
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Step II: Augmentative Communication/Speech Generating Device Evaluation
1. Background Information
Team Members Planning to Attend Evaluation Present at Evaluation?
Educational History In Grade Level:
Early Childhood/Preschool
Elementary- Grade: ___________
College
Other
Completed Grade:
Elementary School High School College Post-Graduate Other
Type of Program:
Special Education General Education Combination of Special and General Education Other:
No School
Current Therapy Services: Therapy Frequency Site Therapist/Phone #
Speech Therapy
Occupational Therapy
Physical Therapy
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Other:
Medical History (add pertinent medical procedures, history, medications, if any)
Vocational History:
Unemployed
Attends workshop/day program: __________________________________
Employed at _________________________________________________
Additional Comments (vocation)
Additional Comments (Background Information):
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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2. Speech and Language Status
Speech and Language Status Determined by:
report (e.g. client, family, other therapists, teachers)
informal assessment
formal testing
Formal Tests Administered and Results:
Receptive Language: No deficits in Comprehension
Comprehends:
single words
phrases
sentences
conversation
one-step directions
two-step directions
multiple-step directions
yes/no questions
choice questions
wh-questions
Additional information:
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Expressive Language Communicates Using:
facial expression
pointing
gestures
eye gaze
formal signs
vocalizations
speech at the word level sentence level
objects/pictures/symbols/printed words
voice output communication device
Speech Intelligibility:
____% intelligible with familiar listeners
____% intelligible with unfamiliar listeners
Additional Information:
Written Language
Produces by handwriting: Produces by typing:
Given single words (with or
without symbols), produces:
Nothing Nothing Nothing
Letter Letter 2-3 word phrases
Words (copying) Words (copying) Simple sentences
Words (independently) Words (independently) Complex sentences
Sentences Sentences
Paragraphs Paragraphs
Adaptations For Typing
Standard keyboard ABC keyboard
Writing tool adapted Spelling on device
QWERTY keyboard Word prediction support
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Reading
Functional Reading Comprehension Reading Comprehension Level
Nothing Age-appropriate (at grade level)
Sight words only Below age-level (grade level)
Sentences Approximate Grade Level:
Paragraphs
Additional Information:
Cognition
Memory for tasks presented:
within functional limits
partially limited
severely limited
Attention to tasks presented:
within functional limits
partially limited
severely limited
Learning:
demonstrated new learning during this evaluation (e.g., new techniques, devices).
Summary:
possesses the cognitive abilities to effectively use an augmentative communication device to achieve
functional communication goals.
Additional Information (Cognition):
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Summary of Speech and Language Status o Emergent/Functional
o Difficult to fully assess receptive language o Beginning to communicate using a variety of methods (gestures, body language, facial
expressions, simple symbols) o Requires assistance from the communication partner o Communicates a limited number of messages in a small set of specific contexts or routines
o Context Dependent/Situational
o Understands simple and clear symbols; beginning to understand more abstract symbols. o Understands most communication about things that are preent. May misunderstand references to
people, situations and items that are not present o Communicates effectively in a limited nmber of situations OR communicates in a limited way
across a variety of situations o Overall ability to communicate effectively depends on the environment, topic or communication
partner o Has very limited ability to creatively combine symbols to create new messages o Limited literacy skills
o Independent/Creative
o Age appropriate receptive language o Follows the linguistic rules appropriate for his/her age o Writes and spells at or near age level o Able to combine single words, spelling, and phrases together to create novel and flexible
messages about variety of subjects.
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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3. Current Communication Needs
Environments: please check all environments the client participates in
Home/Residence
School
Work
Medical Facility
Face-to-Face
Telephone
Community
Support Group
Other:
______________________
Partners: please check all partners with whom the client interacts
Immediate Family
Extended Family
Friends
Peers
Co-Workers
Medical professionals
Home health assistants/caregivers
Individuals in the community
Other___________________
Teachers
Residential staff
Topics: please check all topics about which the client needs to communicate
Activities of Daily Living (ADLs)
Medical needs
Medical/Personal/Legal decision-making
Emergency needs/information
Personal needs
Personal information
Other: _________________________
Functions:
Ask questions
Respond to questions
Social interaction (family and community)
Social etiquette
Resolve/prevent communication breakdowns
Other: _________________________
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Summary and Prognosis:
Choose one of the following:
Daily functional communication needs cannot be met using natural speech or low-tech/no-tech augmentative
communication techniques.
OR
Improvements in the quantity and intelligibility of clietn’s speech are unlikely, possible, expected
at this time. At this time, verbal skills do not allow him/her to meet all of his/her daily communication needs
nor do they allow him/her to continue to develop/ regain age-appropriate language skills.
OR
Client has a degenerative condition for which traditional speech/language therapy is not effective. His/her
natural speech does not allow him/her to meet the majority of his/her daily communication needs.
Additional information:
Prognosis for functional use of an augmentative communication system:
excellent good fair poor
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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4. Sensory and Motor
The focus of this section is to provide information regarding vision, hearing and motor skills as they relate to
the use of an augmentative communication device. Information for parts of this section may be provided by an
occupational therapist, if one is involved in the evaluation process.
Vision unaided and functional for AAC use
corrected (glasses/contacts) and functional for
AAC use
functional use of AAC system required vision
accommodations (check necessary
accommodations)
Concerns regarding functional visual processing
(cortical visual skills) in absence of acuity difficulty
Vision Accommodations: increased font size
increased symbol size color contrast
auditory feedback other:
Hearing unaided and functional for AAC use
Hearing Aids L R bilateral and
functional for AAC use
Modifications needed (with/without hearing
aids)
Hearing Accommodations: increased volume
visual cues (display of message, highlight on activation)
headphones dual display for communication
other:
Additional information related to visual and hearing abilities of client or family members/caregivers:
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Motor: Mobility:
no assistive devices
a cane
a quad cane
a walker
a manual wheelchair ( self-propelled or partner-dependent)
a power wheelchair ( joystick, head array, or sip and puff switch)
a scooter
Head:
Control: complete partial, no
Functional Movement: complete partial, no
Hand Use:
Control: complete partial, no
Functional Movement: complete partial, no
Accuracy for Touching Targets: phone keyboard computer keyboard
alternate keyboards: button size ______
Additional information:
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Step III: Hands-On Trials and Results 4. Required Features
Use this section to identify features of a communication device that must be present for your client to be the
most functional communicator possible. Some features may be needed immediately and others may be needed
for language growth and development. You may include a large number of features here. You will use this list to
justify your equipment recommendation in a later section.
Required Features
Language
Message generation via spelling (language structure)
Message generation via combinations of single words (language structure)
Message generation via pre-stored messages (language use)
Combination of message generation modes for quick communication and creation of novel messages
(language use and language structure)
Variety of symbols to represent words or concepts
Ability to use digital photos to represent words or concepts
Ability to use scenes to set the context for communication
Word, character, and phrase prediction to speed rate of communication or decrease effort
when spelling
Other: ______________________________________________________________________
______________________________________________________________________
Access
Carrying case for protection while device is being transported and used
Wheelchair mounting system for easy and safe access in all environments
Desk mount for access at various tabletops
Standard size keyboard for touch typing to optimize communication speed
Keyboard to allow for exploration and literacy learning
Keyboard to allow for spelling of novel messages
Multiple keyboard layouts
Adjustment of access settings (e.g., hold time, scanning speed) to best meet patient’s needs
Accessible via direct selection
Accessible via eye gaze
Accessible via keyguard
Accessible via mouse or mouse alternative (e.g., trackball, Head Mouse, Tracker)
Accessible via joystick
Accessible via one- or two- switch scanning
Accessible via Morse code
Accessible via multiple modes to accommodate for changes in condition over time
Other: ______________________________________________________________________
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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______________________________________________________________________
Device Characteristics Portability for use in multiple environments
Durability to withstand daily use
Battery power to allow for use throughout the day
Voice output for communication in all environments
Synthesized speech for production of novel messages
Feedback (e.g., button click, message window highlight) to assist in message preparation/selection
Dual display for interactions with hearing impaired individuals or in noisy environments
Flexible font size and color for clearest visual presentation
Flexible number and size of messages per page for optimal ease of use and comprehension
Ability to save, retrieve, and edit longer files for use during story telling, speeches, and
caregiver direction
Other: ______________________________________________________________________
______________________________________________________________________
Connections to the World
Telephone access to allow for communication of emergency information
Control of electronic appliances (e.g., lights, fan) for increased independence
Email/texting capability for interaction with community (medical appointments, information, vocational
interactions etc)
Internet accessibility for interaction with community (medical appointments, information, vocational
interactions etc)
Other: ______________________________________________________________________
______________________________________________________________________
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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5. ASSESSMENT OF SPECIFIC EQUIPMENT AND TECHNIQUES- Use one form per device trialed.
Fill in details, check items patient can accomplish, mark N/A for features not available on this device
Trial One: DEVICE/SOFTWARE/MATERIALS: ___________________
TRIAL SPECIFICS
Length of Trial:
Considered but rejected without trial due to:
inability to meet required features lack of symbols to represent language
lack of voice output limited ability to meet communication needs in the near future
weight or size limiting portability small size not meeting physical or visual needs
other:
Describe concerns: _______________________________________________________________
Trial during evaluation session Longer trial (> 1 week) for ________________________
On-Going Trials with loaned equipment
daily
weekly
monthly
On-Going Access to Equipment (evaluation for purpose of assessing effectiveness of current equipment)
Additional Information:
Techniques To Elicit Communication:
discussion response to questions role play functional activity (play, look at magazine)
other: (describe) ________________________________________________________________
Describe Evaluation Stimulus Activities:
Care for Device: independent transport of device partner transport of device
independent battery/charger maintenance partner assisted battery maintenance
turn on/off independent on/off with partner assistance
volume control independently partner assisted volume control
independent programming capability partner assisted programming
programming will be accomplished by partners
Size of Display/Screen: 6” screen 7” screen 10” screen 12” screen 15” screen
Size of Symbols: Keyboard 1” 2” >3”
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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ACCESS METHODS: (consider physical, sensory, behavioral and attention skills and needs)
Direct Selection with Touch, with touch enter delay, with touch exit delay (to decrease accidental
activation or repetitive tapping)
Keyguard: number of locations= 6 8 12 15 20 30 40 60 100 150
Range of Motion: Sufficient on Left Right Both
_______________________________________________________________________________________
Scanning:
Scan Type: Automatic Scanning with Single Switch
Single Switch with Dwell Select with ______ second hold to select
2-Switch (switch to move scan target + switch to select)
Scan Cues: Zoom Highlight Border Highlight Inversion Highlight
Auditory Scan Cue: voice selection ___________________
Private Speaker Output
Device Speaker Output at _____ volume
Scan Pattern: Row/Column
Column/Row
Left/Right
Left/Center/Right
Six Zones
Linear
Top/Bottom
_______________________________________________________________________________________
Joystick/Mouse: Selection Via: Pause External Switch Fire (joystick only)
Zoom Highlight Border Highlight Inversion Highlight
Audio Feedback: voice selection ________________________________
Private Speaker Output
Device Speaker Output at _____ volume
Speed: ____________________
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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_______________________________________________________________________________________
Eye Tracking/Eye Gaze:
Selection Via: Blink Dwell
Hold Time: ________________seconds
Zoom Highlight Border Highlight Inversion Highlight
Fill Type: Bottom Up Contract Drain (color to no color)
Audio Feedback Click yes no
Calibration: both eyes left eye right eye
_______________________________________________________________________________________
Other:_____________________________________
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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COGNITIVE ACCESS TRIAL #1:___________________________________________
Size of Symbols Necessary for Attention/Focus:
Keyboard 1” 2” >3”
Number of Symbols on Page: 2-4 8 12 20
40 60 >100
Navigation: single page, no navigation can navigate pages – list pages:_____________________
Navigation Support: independent verbal prompts taught in context repetition hand over hand
visual cue-button shape, highlight taught in context partner assisted navigation
Type of Symbol: Object Photograph Symbol Word Spelling
Page Format: Grid Free Form Scene
Vocabulary Organization: (check all that apply)
Generative/Creative Word Based (ex: Gateway)
Context Based (scenes or grids related to particular settings
Activity Based (scenes/grids related to specific activities
Pragmatically Organized (function- ex: want something, greetings, something’s
wrong…)
Quick Messages (yes/no, hi/bye, let me/you do it, more/all done, good/bad)
Message Unit: Sentence Phrase Word Letter
Mean Length of
Utterance/Word
Based:
1 word 2 words 3-5 words using carrier
phrases only
Ex: I want…I see…I go…I
like…
on single page
with navigation to other
pages to complete sentence
>3 words independently
combined
on single page
with navigation to
other pages to
complete sentence
Functions: exploration/learning request respond comment share information reject
social exchange escape
Vocabulary Expansion: Multiple levels Dynamic Display Encoding
Editing Functions: close popup delete clear message
Rate: Word prediction Abbreviation expansion Pre-stored messages
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Trial #2: DEVICE/SOFTWARE/MATERIALS: ___________________
TRIAL SPECIFICS
Length of Trial:
Considered but rejected without trial due to:
inability to meet required features lack of symbols to represent language
lack of voice output limited ability to meet communication needs in the near future
weight or size limiting portability small size not meeting physical or visual needs
other:
Describe concerns: _______________________________________________________________
Trial during evaluation session Longer trial (> 1 week) for ________________________
On-Going Trials with loaned equipment
daily
weekly
monthly
On-Going Access to Equipment (evaluation for purpose of assessing effectiveness of current equipment)
Additional Information:
Techniques To Elicit Communication:
discussion response to questions role play functional activity (play, look at magazine)
other: (describe) ________________________________________________________________
Describe Evaluation Stimulus Activities:
Care for Device: independent transport of device partner transport of device
independent battery/charger maintenance partner assisted battery maintenance
turn on/off independent on/off with partner assistance
volume control independently partner assisted volume control
independent programming capability partner assisted programming
programming will be accomplished by partners
Size of Display/Screen: 6” screen 7” screen 10” screen 12” screen 15” screen
Size of Symbols: Keyboard 1” 2” >3”
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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ACCESS METHODS: (consider physical, sensory, behavioral and attention skills and needs)
Direct Selection with Touch, with touch enter delay, with touch exit delay (to decrease accidental
activation or repetitive tapping)
Keyguard: number of locations= 6 8 12 15 20 30 40 60 100 150
Range of Motion: Sufficient on Left Right Both
_______________________________________________________________________________________
Scanning:
Scan Type: Automatic Scanning with Single Switch
Single Switch with Dwell Select with ______ second hold to select
2-Switch (switch to move scan target + switch to select)
Scan Cues: Zoom Highlight Border Highlight Inversion Highlight
Auditory Scan Cue: voice selection ___________________
Private Speaker Output
Device Speaker Output at _____ volume
Scan Pattern: Row/Column
Column/Row
Left/Right
Left/Center/Right
Six Zones
Linear
Top/Bottom
_______________________________________________________________________________________
Joystick/Mouse: Selection Via: Pause External Switch Fire (joystick only)
Zoom Highlight Border Highlight Inversion Highlight
Audio Feedback: voice selection ________________________________
Private Speaker Output
Device Speaker Output at _____ volume
Speed: ____________________
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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_______________________________________________________________________________________
Eye Tracking/Eye Gaze:
Selection Via: Blink Dwell
Hold Time: ________________seconds
Zoom Highlight Border Highlight Inversion Highlight
Fill Type: Bottom Up Contract Drain (color to no color)
Audio Feedback Click yes no
Calibration: both eyes left eye right eye
_______________________________________________________________________________________
Other:_____________________________________
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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COGNITIVE ACCESS: TRIAL #2: ___________________________________________
Size of Symbols Necessary for Attention/Focus:
Keyboard 1” 2” >3”
Number of Symbols on Page: 2-4 8 12 20
40 60 >100
Navigation: single page, no navigation can navigate pages – list pages:_____________________
Navigation Support: independent verbal prompts taught in context repetition hand over hand
visual cue-button shape, highlight taught in context partner assisted navigation
Type of Symbol: Object Photograph Symbol Word Spelling
Page Format: Grid Free Form Scene
Vocabulary Organization: (check all that apply)
Generative/Creative Word Based (ex: Gateway)
Context Based (scenes or grids related to particular settings
Activity Based (scenes/grids related to specific activities
Pragmatically Organized (function- ex: want something, greetings, something’s
wrong…)
Quick Messages (yes/no, hi/bye, let me/you do it, more/all done, good/bad)
Message Unit: Sentence Phrase Word Letter
Mean Length of
Utterance/Word
Based:
1 word 2 words 3-5 words using carrier
phrases only
Ex: I want…I see…I go…I
like…
on single page
with navigation to other
pages to complete sentence
>3 words independently
combined
on single page
with navigation to
other pages to
complete sentence
Functions: exploration/learning request respond comment share information reject
social exchange escape
Vocabulary Expansion: Multiple levels Dynamic Display Encoding
Editing Functions: close popup delete clear message
Rate: Word prediction Abbreviation expansion Pre-stored messages
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Trial #3: DEVICE/SOFTWARE/MATERIALS: ___________________
TRIAL SPECIFICS
Length of Trial:
Considered but rejected without trial due to:
inability to meet required features lack of symbols to represent language
lack of voice output limited ability to meet communication needs in the near future
weight or size limiting portability small size not meeting physical or visual needs
other:
Describe concerns: _______________________________________________________________
Trial during evaluation session Longer trial (> 1 week) for ________________________
On-Going Trials with loaned equipment
daily
weekly
monthly
On-Going Access to Equipment (evaluation for purpose of assessing effectiveness of current equipment)
Additional Information:
Techniques To Elicit Communication:
discussion response to questions role play functional activity (play, look at magazine)
other: (describe) ________________________________________________________________
Describe Evaluation Stimulus Activities:
Care for Device: independent transport of device partner transport of device
independent battery/charger maintenance partner assisted battery maintenance
turn on/off independent on/off with partner assistance
volume control independently partner assisted volume control
independent programming capability partner assisted programming
programming will be accomplished by partners
Size of Display/Screen: 6” screen 7” screen 10” screen 12” screen 15” screen
Size of Symbols: Keyboard 1” 2” >3”
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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ACCESS METHODS: (consider physical, sensory, behavioral and attention skills and needs)
Direct Selection with Touch, with touch enter delay, with touch exit delay (to decrease accidental
activation or repetitive tapping)
Keyguard: number of locations= 6 8 12 15 20 30 40 60 100 150
Range of Motion: Sufficient on Left Right Both
_______________________________________________________________________________________
Scanning:
Scan Type: Automatic Scanning with Single Switch
Single Switch with Dwell Select with ______ second hold to select
2-Switch (switch to move scan target + switch to select)
Scan Cues: Zoom Highlight Border Highlight Inversion Highlight
Auditory Scan Cue: voice selection ___________________
Private Speaker Output
Device Speaker Output at _____ volume
Scan Pattern: Row/Column
Column/Row
Left/Right
Left/Center/Right
Six Zones
Linear
Top/Bottom
_______________________________________________________________________________________
Joystick/Mouse: Selection Via: Pause External Switch Fire (joystick only)
Zoom Highlight Border Highlight Inversion Highlight
Audio Feedback: voice selection ________________________________
Private Speaker Output
Device Speaker Output at _____ volume
Speed: ____________________
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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_______________________________________________________________________________________
Eye Tracking/Eye Gaze:
Selection Via: Blink Dwell
Hold Time: ________________seconds
Zoom Highlight Border Highlight Inversion Highlight
Fill Type: Bottom Up Contract Drain (color to no color)
Audio Feedback Click yes no
Calibration: both eyes left eye right eye
_______________________________________________________________________________________
Other:_____________________________________
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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COGNITIVE ACCESS TRIAL #3:________________________________________________
Size of Symbols Necessary for Attention/Focus:
Keyboard 1” 2” >3”
Number of Symbols on Page: 2-4 8 12 20
40 60 >100
Navigation: single page, no navigation can navigate pages – list pages:_____________________
Navigation Support: independent verbal prompts taught in context repetition hand over hand
visual cue-button shape, highlight taught in context partner assisted navigation
Type of Symbol: Object Photograph Symbol Word Spelling
Page Format: Grid Free Form Scene
Vocabulary Organization: (check all that apply)
Generative/Creative Word Based (ex: Gateway)
Context Based (scenes or grids related to particular settings
Activity Based (scenes/grids related to specific activities
Pragmatically Organized (function- ex: want something, greetings, something’s
wrong…)
Quick Messages (yes/no, hi/bye, let me/you do it, more/all done, good/bad)
Message Unit: Sentence Phrase Word Letter
Mean Length of
Utterance/Word
Based:
1 word 2 words 3-5 words using carrier
phrases only
Ex: I want…I see…I go…I
like…
on single page
with navigation to other
pages to complete sentence
>3 words independently
combined
on single page
with navigation to
other pages to
complete sentence
Functions: exploration/learning request respond comment share information reject
social exchange escape
Vocabulary Expansion: Multiple levels Dynamic Display Encoding
Editing Functions: close popup delete clear message
Rate: Word prediction Abbreviation expansion Pre-stored messages
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Trial 1: _________________________________
Conclusion:
Most appropriate device at this time
Meets some needs, but will continue looking with the following concerns:
Trial 2: _________________________________
Conclusion:
Most appropriate device at this time
Meets some needs, but will continue looking with the following concerns:
Trial 3: _________________________________
Conclusion:
Most appropriate device at this time
Meets some needs, but will continue looking with the following concerns:
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Step IV: Post-Evaluation Recommendations and Follow-Up Planning 6. Summary and Recommendations
SGD AND ACCESSORIES RECOMMENDED
Check recommended device and accessories:
DEVICE
Dynavox Maestro
Dynavox Tango
Dynavox V
Dynavox Vmax
Dynawrite
Dynavox Xpress
PRC Springboard
PRC Vantage Lite
PRC Echo
Saltillo Alt-Chat
Saltillo Silk
Saltillo NovaChat 7
Saltillo NovaChat 10
Tobii C8
Tobii C12
iTouch
iPad
Other:
SWITCH
Buddy Button
Big Buddy Button
Microlight
Plate Switch
Cap Switch
Cup Switch
Mini Cup
Square Pad
Soft
Trigger Switch
Switch Joystick with Push
Mini Joystick
SCATIR
Other:
ACCESSORY
Extra Charger
Headmouse
Tracker
Headpointer
Switch Mount
Eye Gaze Camera: __________________
Carrying Case
Accessible Carrying Case
Extra Battery
Other:
SOFTWARE/APPs
Series 5 Speaking Software
Speaking Dynamically Pro
Boardmaker Studio
The Grid
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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iOS App
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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7. Treatment Plan and Follow-Up
INTERVENTION SCHEDULE
Recommended Follow-Up:
No follow-up treatment
Limited number of follow-up treatment sessions after receipt of device: _______ (#)
On-going therapy with _________minutes per session; __________number of sessions per week
Individual therapy recommended
Group treatment recommended
Treatment is available at: _________________________________________________
INITIAL TREATMENT GOALS FOR DATES: _______________________________________
Example Goals: Select from example goals below that are most appropriate for patient or use Goals Grid
examples
Operational:
Using written instructions will program at least 10 messages on existing pages with ____ % accuracy
(within ______week/months).
Patient will demonstrate the ability to program messages with ______ % accuracy
(within ______week/months).
Patient will demonstrate comprehension of basic maintenance and operations
(on-off, adjusting volume) of the device with _____ % accuracy (within ______week/months).
Other:__________________________________________________________________________
Basic Communication:
Patient will call for help from a spouse/caregiver in another room in emergency situations with ____%
accuracy (within ______week/months).
Given a specific message to find, patient will navigate to the correct page
independently
with minimal cues
with moderate cues with ____ % accuracy (within ______week/months).
During conversation, patient will navigate to the correct page
independently
with minimal cues
with moderate cues with ____ % accuracy (within ______week/months).
Patient will communicate basic/medical needs and feelings to family/caregivers with _____% accuracy
(within ______week/months).
Patient will greet and initiate conversation
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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independently
with minimal cues
with moderate cues with _____% accuracy (within ______week/months).
Patient will ask questions, respond to questions, and express opinions
independently
with minimal cues
with moderate cues with ____% accuracy (within ______week/months).
Patient will communicate basic personal information
independently
with minimal cues
with moderate cues with _____ % accuracy (within ______week/months).
When asked, patient will select desired activities
independently
with minimal cues
with moderate cues with ____ % accuracy (within ______week/months).
Other: ____________________________________________________________________________
Language Learning:
Patient will use the (recommended device) to make simple sentences (e.g.., subject + verb + object)
appropriate to the current activity page
independently
with minimal cues
with moderate cues with _____% accuracy (within ______week/months).
Using: core words keyboard combination of core words and spelling,
Patient will formulate _________word sentences appropriate to the current activity
independently
with minimal cues
with moderate cues with _____% accuracy (within ______week/months).
Patient will use word prediction to spell a core set of 3-5 letter words
independently
with minimal cues
with moderate cues with _____% accuracy (within ______week/months).
Other:______________________________________________________________________________
Communication in the Community:
Patient will participate in a phone conversation
independently
with minimal cues
with moderate cues with _____% accuracy (within ______week/months).
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Patient will describe physical symptoms and ask questions while interacting with a physician or other
healthcare provider
independently
with minimal cues
with moderate cues with _____ % accuracy (within ______week/months).
Patient will engage in social interactions with friends in a variety of community settings
independently
with minimal cues
with moderate cues with ____ % accuracy (within ______week/months).
Patient will ask questions and respond in community-based interactions
(e.g., at the bank, ordering in a restaurant)
independently
with minimal cues
with moderate cues with ____ % accuracy (within ______week/months).
Patient will participate in support groups
independently
with minimal cues
with moderate cues with ____ % accuracy(within ______week/months).
Other:______________________________________________________________________________
Self-Advocacy:
Patient will instruct caregivers about care requirements and preferences
independently
with minimal cues
with moderate cues with ____ % accuracy (within ______week/months).
Patient will participate in family and medical planning decisions
independently
with minimal cues
with moderate cues with ____ % accuracy (within ______week/months).
Other:____________________________________________________________________________
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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PATIENT/FAMILY SUPPORT OF SGD
Responsible Parties
Patient Family Caregiver
(name)
__________
Manufacturer
Representative
(name)
______________
Therapist
(name) ______________
______________
Other
(name)
______
Therapy to address
above goals
Continued trials
with SGD
N/A- not
recommended
Group tx:
Individual tx:
Group/Individual
therapy:
Initial Training
Initial Customization
(programming,
vocabulary selection,
intervention planning)
On-Going Training
and Modification
Maintenance of
Device
Warranty
Maintenance
Management
NECESSARY FUNDING PAPERWORK
Check when obtained Date
Medicaid/Insurance Cards Copied
Benefits Assignment Signed by Parent/Consumer
Doctor’s Prescription
AAC/SGD Evaluation Written
Quote from Manufacturer
Dynamic Therapy Associates, Inc. Speech Language Pathology and Assistive Technology
3105 Creekside Village Dr., Ste. 604, Kennesaw, GA 30144
Ph: 770-974-2424 Fax: 1-866-384-6451
[email protected] www.mydynamictherapy.com
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Long Term Goal and Expected Outcomes: Patient will communicate functionally in his/her home, school
and community to meet medical, social and life needs using a combination of speech, written and voice output
device communication.
Clinical Provider: _________________________ __________________________________
Vicki K. Clarke, MS CCC-SLP date
Physician Involvement Statement: It is in my opinion that patient requires the therapeutic services as described in the above Evaluation and Plan
of Treatment in order to meet a medically necessary level of functioning.
Physician Signature:________________________________ Date: _________________________________
cc: parent, physician, clinic file, Medicaid records
*Content adapted from The Funding Manager software, copyright 2008, Dynavox Technologies, Pittsburgh,
PA
Georgia Project for Assistive Technology www.gpat.org Permission to photocopy is granted for non-commercial purposes if this credit is retained.
1
Augmentative Communication Evaluation Summary
Student: Date of Birth: Age: Date(s) of Evaluation: System:
Access Evaluation Informal measures were utilized to evaluate the student’s access skills. The following is a summary of his/her performance: Direct Selection:
Student could utilize direct selection to access targets (i.e., toys, familiar objects, manipulatives, etc.) placed within easy reach using
Hand left right both Finger - Specify: _____ left right both Other – Specify: Eyegaze response - Describe eyegaze response including optimal symbol size,
placement, etc. When using direct selection, the student: Consistently accessed targets No Yes Crossed midline to access targets No Yes Required significant response time No Yes - Specify: Required a large target area No Yes - Specify: Accessed symbols in all locations No Yes - If No, explain:
(If student is able to utilize direct selection, skip remainder of access section and move to Symbol Evaluation) Adapted Direct Selection:
Student could utilize adapted equipment to access targets using Splint Head pointer Keyguard/grid Mouthstick Adapted pointer – Describe
Student could utilize computer based adapted direct selection using:
Mouse Trackpad Trackball Joystick keyguard/grid Keyboard Head pointing system Mouse Mover
(Complete Computer Access Evaluation for more information, if needed)
Using the devices listed above, the student:
Required use of Accessibility Features in Windows operating system – Specify: Moved the mouse in designated direction: right left up down diagonally Visually tracked mouse arrow or highlight Navigated to desired locations on communication device Executed a single click to activate location Executed a double click to open an application Maintained a steady position long enough to execute a dwell function activation Consistently accessed targets Crossed midline to access targets Required significant response time If Yes - Specify: Required a large target area If Yes - Specify: Accessed symbols in all locations Other – Specify
Comments:
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2
Switch Access: Student could not use direct or adapted direct selection to access symbols. The following alternative input method was assessed during this evaluation: (use a variety of tools, such as toys, computer software, power control units, etc.) The following switches were used during this evaluation:
Switch Activation Site Location/ Mount
Activate Hold/ Maintain
Release Reactivate
ex: Big Red right hand laptray/right side
yes maintain for 2/3 seconds
unable to release without cues
needs verbal cues
Switch responses were: Spontaneous Verbally cued Visually cued Partial Physical Assistance Full Physical Assistance
Switch access used by the student:
Remote switch access # of switches # of switches Switch type Switch type
Scanning switch access Scan Mode Scan Method Visual scanning Automatic scanning Auditory scanning Directed (step) scanning Inverse scanning Scan Pattern Other – Specify: Linear Row/Column Block/Row/Column Customized – Specify:
Morse Code access # of switches Switch type
Symbol Evaluation Informal measures were utilized to evaluate the student’s symbolic skills. The following is a summary of his/her performance: Symbol Identification:
Student was unable to participate in a formal symbol evaluation due to Symbol usage was assessed during device evaluation.
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3
Student was able to complete a formal symbol evaluation. The following symbols were used:
Referent Object
Specify Type
Photograph Realistic Picture Line Drawing
Size:
Printed Text
Size:
Using the symbols evaluated above, the student: Could not use symbolic representation due to Identified object/tactile/tangible representation system – Specify Identified photographic representation system Identified realistic picture representation system Identified line drawing representation system (PCS, DynaSyms, etc.) Identified text based symbols – Specify: letter word
Using the representation system listed above, the student:
Could identify symbols by (check all that apply): label/name function action size color category association
Student was able to view and utilize up to ______ symbols in a: linear row/column
arrangement Symbol Accommodations for Vision Needs: (Consult with Vision Specialist if student diagnosed with vision impairment)
Student required symbol adaptations to accommodate visual needs: large symbol size – Specify: high contrast spacing between symbols grid separating symbols textured symbol system tangible symbol system Symbol/Vocabulary Usage: Using the symbols introduced in the Symbol Identification Evaluation, the student’s ability to use symbols as a means of communication and expressive language was assessed through informal measures.
Student used symbols with communicative intent for the following purposes: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject
Student did so with the following level of support: spontaneous model verbal prompt visual prompt gesture hand/hand facilitation (student directed) partial physical assistance full physical assistance (adult directed)
Student sequenced vocabulary to generate phrases/sentences – Specify number of symbols ___ Student required prompts to sequence vocabulary
Level of prompting required: model visual verbal physical
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4
Augmentative Devices Evaluated
Based on information obtained in the accessing and symbol evaluation areas, communication systems with the following features were presented:
Non-voice output systems:
System(s) utilized: Object board/box Describe:
Eyegaze board Describe:
Picture exchange system Describe:
Picture book/board Describe:
Picture wallet Describe:
Word board Describe:
Letter board Describe:
Visual schedule Describe:
Activity Utilized classroom activity game toys social routine other – specify:
Access: Direct selection hand left right finger left right
Adapted direct selection adapted pointer head pointer
Scanning access: Live voice/Partner assisted
scanning Partnered visual scanning
Symbol System: Symbol type: object/tangible/tactile photograph realistic picture line drawing text based spoken prompt/cue
Symbol arrangement: linear row/column
Number of symbols utilized: Initial Final
Symbol recognized by: label/name function action size color category association
Vocabulary Usage: Communicative intent: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject
Vocabulary sequencing: Number of symbols sequenced: independently with prompts
Level of prompting: model visual verbal physical
Vocabulary Organization:
single message phrase based single word combination – Specify:
Comments:
Georgia Project for Assistive Technology www.gpat.org Permission to photocopy is granted for non-commercial purposes if this credit is retained.
5
Single level static display systems:
Device(s) utilized: Activity Utilized classroom activity
game toys social routine other – specify:
Access: Direct selection hand left right finger left right
Adapted direct selection adapted pointer head pointer
Switch access: remote switch
# of switches switch type
Access: Direct selection hand left right finger left right
Adapted direct selection adapted pointer head pointer
Symbol System: Symbol type: object/tangible/tactile photograph realistic picture line drawing text based
Symbol arrangement: linear row/column
Number of symbols utilized: Initial Final
Symbol recognized by: label/name function action size color category association
Vocabulary Usage: Communicative intent: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject
Vocabulary sequencing: Number of symbols sequenced: independently with prompts
Level of prompting: model visual verbal physical
Vocabulary Organization:
single message phrase based single word combination – specify: Fitzgerald Key Arrangement
Activity Based Minspeak
Comments:
Georgia Project for Assistive Technology www.gpat.org Permission to photocopy is granted for non-commercial purposes if this credit is retained.
6
Multiple level static display systems:
Device(s) utilized:
Activity Utilized classroom activity game toys social routine other – specify:
Access: Direct selection hand left right finger left right
Adapted direct selection
adapted pointer head pointer joystick
Switch Access Scanning access
Scan mode: Visual scanning Auditory scanning
Scan method: Automatic scanning Directed (step) scanning Inverse scanning
Other – Specify Scanning pattern:
Linear Row/Column Block/Row/Column
Custom – Specify: Morse Code
# of switches switch type
Symbol System: Symbol type: object/tangible/tactile photograph realistic picture line drawing text based
Symbol arrangement: linear row/column
Number of symbols utilized: Initial Final
Symbol recognized by: label/name function action size color category association
Vocabulary Usage: Communicative Intent: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject
Vocabulary sequencing: Number of symbols sequenced: independently with prompts
Level of prompting: model visual verbal physical
Vocabulary Organization:
single message phrase based single word combination – specify: Fitzgerald Key Arrangement
Activity Based Minspeak
Related Skills: Student could independently/physically change overlays Student could utilize multiple levels Student could change levels on the device Student could match appropriate overlay to level Student could select appropriate overlay for activity Student could utilize volume control on device
Comments:
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7
Dynamic display systems: dedicated integrated
Device(s)/software utilized: Type of Speech Output: Digitized Synthesized
Activity Utilized classroom activity game toys social routine other – specify:
Access: Direct Selection hand left right finger left right
Adapted direct selection adapted pointer head stick
Computer based adapted direct selection mouse trackpad trackball joystick keyboard head pointing system mouse mover
Switch Access Scanning access
Scan mode: Visual scanning Auditory scanning
Scan method: Automatic scanning Directed (step) scanning Inverse scanning
Other – Specify Scanning pattern:
Linear Row/Column Block/Row/Column
Custom – Specify: Morse Code
# of switches switch type
Symbol System: Symbol type: photograph realistic picture line drawing text based
Symbol arrangement: linear row/column
Number of symbols utilized: Initial Final
Symbol recognized by: label/name function action size color category association
Vocabulary Usage Communicative Intent: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject
Vocabulary sequencing: Number of symbols sequenced: independently with prompts
Level of prompting: model visual verbal physical
Vocabulary Organization:
single message phrase based single word combination – specify: Fitzgerald Key Arrangement
Activity Based Minspeak
Related Skills:: Student could demonstrate categorization skills in number of topic areas Student could use recall memory to locate vocabulary not displayed on current screen Student could remember navigational pathways Student could correct errors in navigation Student could generate a single message utilizing multiple pages Student could see communication device display with ease
Advanced Features Student could utilize text to speech function to generate novel messages Student could utilize word prediction to assist with spelling/rate enhancement Student could utilize large vocabulary pool to generate novel messages
Student could use preprogrammed vocabulary software - Specify:
Comments:
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8
Minspeak based systems:
Device(s) utilized: Type of Speech Output: Digitized Synthesized
Activity Utilized classroom activity game toys social routine other – specify:
Access: Direct Selection hand left right finger left right
Adapted direct selection adapted pointer head stick
Computer based adapted direct selection mouse trackpad trackball joystick keyboard head pointing system
Switch Access Scanning access
Scan mode: Visual scanning Auditory scanning
Scan method: Automatic scanning Directed (step) scanning Inverse scanning
Other – Specify Scanning pattern:
Linear Row/Column Block/Row/Column
Custom – Specify: Morse Code
# of switches switch type
Symbol System: Symbol type: photograph realistic picture line drawing text based
Symbol arrangement: linear row/column
Number of symbols utilized: Initial Final
Symbol recognized by: label/name function action size color category association
Vocabulary Usage: Communicative Intent: gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject
Vocabulary sequencing: Number of symbols sequenced: independently with prompts
Level of prompting: model visual verbal physical
Vocabulary Organization:
single message phrase based single word combination – specify:
Activity Based Minspeak
Related Skills:: Student could demonstrate categorization skills in number of topic areas Student could use recall memory to locate vocabulary not displayed on current screen Student could sequence symbols to retrieve vocabulary – specify: Student could remember navigational pathways Student could correct errors in navigation Student could generate a single message utilizing multiple pages Student could see communication device display with ease
Advanced Features Student could utilize text to speech function to generate novel messages Student could utilize large vocabulary pool to generate novel messages
Student could use preprogrammed vocabulary software Specify:
Comments:
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9
Dedicated Letter based systems:
Device(s) utilized: Activity Utilized classroom activity
game toys social routine other – specify:
Access: Direct Selection hand left right finger left right
Adapted direct selection adapted pointer head stick
Computer based adapted direct selection joystick keyboard
Switch Access Scanning access
Scan mode: Visual scanning Auditory scanning
Scan method: Automatic scanning Directed (step) scanning Inverse scanning
Other – Specify Scanning pattern:
Linear Row/Column Block/Row/Column
Custom – Specify: Morse Code
# of switches switch type
Spelling Accuracy: Spelling sufficient to be recognized by text to speech engine: Word prediction is utilized to assist spelling/rate enhancement
Vocabulary Usage: Student could generate sufficient words through spelling to convey thoughts Student could formulate a complete thought or sentence Student could use appropriate grammar when formulating sentences
Related Skills Student could remember navigational pathways Student could correct errors in navigation Student could see communication device display with ease
Advanced Features Student could utilize text to speech function to generate novel messages Student could utilize large vocabulary pool to generate novel messages Student could use word prediction feature to enhance rate
Comments:
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10
Recommendations
Based on the results of this evaluation, the following recommendations are made for this student:
System Recommendations:
At this time, student does not require an augmentative/alternative communication system.
If checked, specify why:
The student would benefit from a non-voice output communication system to supplement device
use or to serve as a beginning means of communication. The following device(s) are suggested:
Object board/box Eyegaze board Picture exchange system Picture book/board Picture wallet Word board Letter board Live voice/Partner assisted scanning Partnered visual scanning Visual Schedule box - Describe: Other
The student would benefit from a voice output augmentative communication device to supplement
his/her existing communication skills. The following device features are recommended at this time:
Voice Output:
Digitized voice output Synthesized voice output Access:
Direct selection access Adapted direct selection Computer based access Remote switch access Single switch access Dual switch access Visual scanning access Auditory scanning access
Physical Features: Large target area Accommodates object symbol Single level Multiple levels Static display Dynamic display Printed output Text to speech capability (spelling) Keyguard/grid Portable Lightweight Wheelchair mount* Shoulder Straps/Carry Case Button Covers (Tech Caps, Snap Switch Caps, etc.)
Vocabulary Features: Activity based Minspeak based Letter/word/text based Large vocabulary capacity Commercially Available Vocabulary Software Packages Other-Specify:
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11
The following system(s) contain(s) the above suggested features and is/are felt to be appropriate for the student’s use at this time. Trial periods should be conducted with each system listed prior to a final determination.
Name of Device: _______________________________ Vendor: *Consultation with Physical Therapist, device manufacturer and wheelchair vendor is suggested for mounting of communication system utilized by non-ambulatory student
Name of Device: _______________________________ Vendor: *Consultation with Physical Therapist, device manufacturer and wheelchair vendor is suggested for mounting of communication system utilized by non-ambulatory student
Name of Device: _______________________________ Vendor: *Consultation with Physical Therapist, device manufacturer and wheelchair vendor is suggested for mounting of communication system utilized by non-ambulatory student
Access Method The student should access symbols on the communication device/display through:
Direct selection: Hand left right both Finger-Specify: _____ left right both
Eyegaze response - Describe eyegaze response including optimal symbol size, placement, etc.
Adapted direct selection: Splint Head pointer keyguard/grid Optical Head pointer Mouthstick Adapted pointer – Describe
Computer based adapted direct selection: Mouse Trackpad Trackball Joystick Keyboard Head pointing system Mouse Mover
The following adaptations are required to enhance student access when using the above access methods:
large symbol size – Specify: high contrast grid separating symbols textured symbol system tangible symbol system Spaces between symbols - Specify: Other adaptations - Specify:
Switch access used by the student:
Remote switch access # of switches # of switches Switch type Switch type
Scanning switch access Scan Mode Scan Method Visual scanning Automatic scanning Auditory scanning Directed (step) scanning Inverse scanning Scan Pattern Other – Specify: Linear Row/Column Block/Row/Column Customized – Specify:
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Morse Code access # of switches Switch type
Symbol System The following symbols are recommended to represent selected vocabulary:
Tangible/Tactile symbols Whole/Real objects (the actual object) Miniature objects (doll-sized representations or magnets) Parts of objects (wheel from a car, button from shirt) Associated Objects (clock for time, straw for drink) Textures or shapes (triangle for eat, circle for drink, sandpaper for places, etc.)
Photographs Realistic picture representation system – Specify: Line drawing representation system – Specify: Text /Printed words – Specify: letter word
In order to enhance access, the most appropriate symbol size is The initial symbol set should not exceed _____ symbols per display. As the student becomes more proficient in identifying and accessing symbols, additional symbols may be added to the display. Additional Comments/Recommendations:
Vocabulary/Symbol Use Vocabulary should be selected to promote participation across communication environments. The following selection method(s) are suggested to assist in selecting appropriate vocabulary for the student:
Ecological/environmental inventory Activity based inventory Social inventory (i.e., social language) Peer observation Student observation Teacher/family/student interview
Vocabulary should also be selected to permit expression of a range of language functions including the following:
gain attention express wants and needs request assistance request recurrence indicate finished express choices make comments express greetings and farewells respond to questions reject
Student should sequence symbols to generate phrases/sentences Yes No
If yes, the student should begin sequencing ______ symbols
Student requires prompts to sequence symbols Yes No If yes, level of prompting required: model visual verbal physical
Vocabulary Organization Selected vocabulary should be programmed using the following language organization method:
Single message Activity Based (single level) Activity based (static multiple levels) Activity Based (dynamic display) Minspeak based (single level with activity row) Minspeak based (dynamic display)
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13
Using the language organization method designated above, vocabulary should be organized utilizing the following language level(s):
Complete messages (i.e., 1 message/1 hit) Combine short phrases (i.e., carrier phrases, noun phrases, verb phrase filler items, etc.) Single Words (i.e., 1 word/1 hit) organized by: activities
categories grammar Fitzgerald Key Arrangement (syntactical format) Color coding to assist word group recognition
Additional Comments/Recommendations:
Strategies to Enhance Device Use When integrating the student’s communication system into the classroom environment, the following strategies should be considered:
Visual Strategies and Cueing The classroom environment should be engineered for successful communication. Use visual supports to enhance communication, behavior, and learning. Use picture-based task analysis to promote independence in task completion. Use a classroom/individual daily picture-based schedule to support transition. Use Super Symbols (behavior cue symbols) to address inappropriate behavior.
Integration The selected communication system should be available to the student throughout the
school day. The communication system should be used in a variety of settings and activities with
appropriate vocabulary. Integrate student’s communication system into behavior modification plan to address
behavioral concerns.
Teaching Strategies Customize AAC displays to include personal vocabulary. Interact with students using AAC in natural situations using natural cues and consequences. Develop a consistent method of cueing/prompting. Model the use of the AAC system by pointing to the appropriate symbol as you speak.
The student’s system should be used as a method to develop receptive language as well as expressive language.
Provide immediate and consistent feedback to a student’s communication attempts. Create communication opportunities throughout the school day. Provide access to a continuum of AAC supports (communication device, communication
boards, communication rings, etc.) Provide multiple modality immersion (signs, pictures, spoken language, gestures, etc.) Develop a method for backing up student’s vocabulary system/device. Consider the use of a flashlight for a supplement or an alternative or to finger pointing. Utilize a preferred/less preferred or nothing/preferred strategy when teaching choice-making.
Staff Supports
All school staff working with the student should receive training in the programming and use of the selected communication device.
Consult with a physical therapist, occupational therapist and/or wheelchair vendor regarding mounting issues.
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Student Progress Data should be collected to verify student’s use of his/her system. The student’s use of the device should be carefully monitored and changes in programming
should be made as needed. Trial use of communication system should be implemented to determine appropriateness.
Additional Comments/Recommendations:
Augmentative Communication Evaluation Conducted by: Name Position Date Name Position Date
AAC Funding
Tools
SPEECH-LANGUAGE PATHOLOGY EVALUATION FOR SPEECH GENERATING DEVICE (SGD)
II. CURRENT COMMUNICATION IMPAIRMENT Impairment Type, Severity The patient presents with __________ due to .
Given the severity of the communication impairment as described above the patient is functionally nonspeaking.
As indicated above, the patient’s speaking rate was words per
minute (WPM). Research on speaking rate and intelligibility in degenerative diseases has found speaking rates less than or equal to 50% of normal (range 190 – 220 WPM) are predictive of imminent precipitous decline (e.g., to the point of no usable speech in less than 3 months) in speech intelligibility.
Anticipated Course of Impairment The patient’s condition is ___________ in nature and __________ is expected to ____________. Therefore it is anticipated that the patient’s natural speech will not be sufficient to meet daily communication needs for ___________ Comprehensive Assessment Hearing Status The patient has _________ of hearing impairment. The patient’s __________ has _________ of hearing impairment. Informal observation of functional listening performance during the SGD assessment revealed the patient and/or caregiver required the following modifications regarding auditory output to use a SGD effectively.
Modification Patient CaregiverNo modifications Headphones Use of dual visual display to read messages Specific speech output options.
NAME: DATE OF EVALUATION: ADDRESS: DATE OF BIRTH: TELEPHONE: AGE: REFERRED BY: MEDICAL DIAGNOSIS: LICENSED SLP: SLP DIAGNOSIS: __________ DATE OF REPORT: DATE OF ONSET:
Name: 2. DOB:
With modifications as listed above, the patient demonstrates adequate hearing ability to use a SGD to communicate functionally. Visual Status The patient has a history of _________. The patient’s __________ has a history of _________. Informal observation of functional visual performance during the SGD assessment revealed the patient and/or caregiver required the following modifications to use a SGD effectively given current vision status.
Modification Patient Caregiver No modifications Font size used on SGD display and/or symbol labels (“gloss”) should be: ________
Picture-symbols and/or icons should be the following size: _______
A flat display is required to reduce visual tracking requirements (e.g., need to alternate focus between keyboard and display to monitor selections)
Color contrasts are needed to enhance text or symbol discrimination such as:
Number of items per display should be: Auditory feedback from device is needed to assist in message preparation/selection.
With modifications as listed above, the patient demonstrates the visual abilities to use a SGD to communicate functionally. Physical Status The patient was able to successfully access SGDs presented at the evaluation with the following selection technique/modifications. Check Selection Technique Type Additional Information
Manual direct selection ________ Optical Direct Selection High Tech Eye Gaze
Direct Selection
Scanning ________, _______
Morse Code _____ Requires access
modifications over time due to degenerative condition
The patient uses ________ for mobility. Therefore, a wheelchair mounting system __________ to transport the patient’s SGD.
Name: 3. DOB:
With the above modifications/considerations, the patient possesses the physical abilities to effectively use a SGD and required accessories to communicate. Language Skills The patient presents with _____ impairment in language functioning as it relates to using an appropriate SGD. Based on patient report and observation of the patient’s language and literacy skills during the evaluation, the patient possesses the following skills/abilities.
Skill/Ability Mastery Follows simple instructions (e.g., “Look at me.” “Turn your head.” “Open your mouth.”)
________
Follows complex instructions ________ Follows general conversation ________ Reads/comprehends common words ________ Reads/comprehends simple sentences ________ Reads comprehends short paragraphs ________ Reads the newspaper ________ Spells common words ________ Generates basic messages using writing/spelling skills ________ Generates complex messages using writing/spelling skills ________ Generates basic messages by using pictographic symbols ________ Generates complex messages using pictographic symbols ________ Generates messages using generative symbols (e.g., MinSpeak™)
________
Given the patient’s language/literacy functioning, a SGD that provides message production using _____________ will be required. Following _______ instruction, the patient demonstrated the linguistic capacity to generate ________ messages on an SGD with__________. The patient’s linguistic performance with the SGDs presented during the evaluation indicated the necessary language skills to functionally communicate using a SGD. Cognitive Skills The patient presents with ______ impairment in cognitive functioning as it relates to ability to use an appropriate SGD. The patient’s attention, memory and problem solving skills observed during the evaluation appeared functional to learn to use a SGD successfully. For example, during the _______ assessment/training trials, the patient demonstrated independence or progress in mastering the following SGD features.
Feature Mastery Turns SGD on and off ________ Navigates within and between display pages on a dynamic display SGD
________
Uses dictionary features to locate vocabulary not available on pre-programmed displays
________
Name: 4. DOB:
Uses word-prediction ________ Retrieves messages stored under letter codes or symbol codes ________ Stores messages under letter codes ________ Stores messages under picture symbols ________ Learns icon-code sequences to retrieve words on SGD (e.g., Unity™ Core)
________
Navigates within SGD “Menu” options to modify device options (e.g., voice, scan rate, feedback).
________
The patient demonstrates the necessary cognitive abilities (i.e., attention, memory, and problem-solving) skills to learn to use a SGD to achieve functional communication goals. III. DAILY COMMUNICATION NEEDS
Specific Daily Functional Communication Needs
The results of a communication needs interview conducted with the patient, relevant family members and caregivers revealed the following communication needs.
Communicative Activity.
Communication to:
Communication Partner(s)
Communicative Environment(s)
Is Need Met with Natural
Speech and/or Low Tech?
Express basic physical needs/wants.
spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger
home medical facility community support group work/school telephone
yes no
NA
Express needs/wants in emergences.
spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger
home medical facility community support group work/school telephone
yes no
NA
Express detailed physical needs/wants.
spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger
home medical facility community support group work/school telephone
yes no
NA
Name: 5. DOB: Participate in decision-making (e.g., discuss choices for end-of-life care).
spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger
home medical facility community support group work/school telephone
yes no
NA
Participate in conversation.
spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger
home medical facility community support group work/school telephone
yes no
NA
Tell personal stories and anecdotes.
spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger
home medical facility community support group work/school telephone
yes no
NA
Report medical status and complaints.
spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger
home medical facility community support group work/school telephone
yes no
NA
Ask questions. spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger
home medical facility community support group work/school telephone
yes no
NA
Give responses. spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger
home medical facility community support group work/school telephone
yes no
NA
Name: 6. DOB: spouse
immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger
home medical facility community support group work/school telephone
yes no
NA
spouse immediate family extended family friends healthcare provider non-reader hearing impaired visually impaired stranger
home medical facility community support group work/school telephone
yes no
NA
Ability to Meet Communication Needs With Non-SGD Treatment Approaches
Speech therapy to improve/increase functional speech is not a viable option to meet the patient’s communication needs because:
The patient’s has a degenerative condition for which speech/language therapy is not effective.
The patient received speech/language treatment for with no significant changes in speech/language functioning.
The patient’s speech/language functioning has been static for and no improvement is expected.
The results of the communication needs assessment as documented in the previous section indicate the majority of patient’s daily functional communication needs cannot be met with natural speech and/or low tech communication devices. Therefore the patient requires a SGD to achieve and/or maintain functional communication ability in activities of daily living.
IV. FUNCTIONAL COMMUNICATION GOALS
The patient’s immediate, short term and long term goals and estimated times to completion following receipt of the recommended SGD are listed below.
Functional Communication Goals Patient will use SGD independently to:
Immediate Short Term
Long Term
Call for help from a spouse/caregiver in another room in emergency. _________
Contact a family member, friend or public agency for help on the
Name: 7. DOB: telephone in emergency. _________ Communicate physical needs and emotional status to spouse/caregiver on a daily basis, as needed. _________
Describe physical symptoms and ask any questions when interacting with physician and other health care professionals as needed. _________
Engage in social communication exchanges with immediate family members in person. _________
Engage in social communication exchanges with extended family members and friends by use of the telephone. _________
Engage in social communication exchanges with friends at their homes and in other community settings. _________
Use the telephone to make contact friends and extended family to interact socially. _________
Ask questions and provide responses in community-based transactions (e.g., ordering a meal in a restaurant, asking directions, etc.) _________
Instruct caregivers on the care requirements (e.g., transfers, bathing, moving from wheelchair to the car.) _________
Participate in family planning decisions (e.g., household management, finances, childrearing, etc.) _________
Participate in support groups. _________ _________ _________ _________
V. RATIONALE FOR DEVICE SELECTION
This individual requires a speech generating device with the following features to meet functional communication goals as stated in the previous section of this report.
Input Features/ Selection Technique
Check Selection Technique Type Rationale Manual direct selection _______ Optical Direct Selection High Tech Eye Gaze
Direct Selection
Scanning _______, _______
Morse Code _______ Provides multiple access
technique options to accommodate changing physical condition
Keyboard Dynamic display
Name: 8. DOB:
Message Characteristics/Features
Check Characteristic or Feature Rationale Message generation using spelling Message generation using a combination
of pre-programmed whole words and spelling
Message generation using pictographic symbols (e.g., PCS, Dynasyms, custom symbols)
Message generation using multi-meaning icon coding (e.g., MinSpeak™)
Message selection using photographs and/or tangible symbols
Ability to adjust font/symbol size to accommodate visual needs
Flat display to reduce visual tracking requirements
Ability to adjust color and contrasts to accommodate visual or cognitive needs
Ability to adjust number of items per display to accommodate visual, physical and/or cognitive needs
Ability to store/edit/retrieve whole messages under word/symbol buttons
Ability to store/edit/retrieve narrative messages (e.g., stories, reports, speeches) from message files
Provides word/symbol prediction rate acceleration techniques
Provides abbreviation expansion (letter coding) rate acceleration techniques
Output Features
Check Feature or Option Specifications if Applicable
Rationale
Synthesized speech Essential for: message generation using
spelling telephone non-reading partners
Name: 9. DOB:
visually impaired partners Digitized speech _______ Essential for:
telephone non-reading partners visually impaired partners
User display size _______ Dual display
(user/listener) Essential for:
hearing impaired partners noisy environments
Auditory feedback from device to assist in message preparation/selection
Other Features
Check Feature or Option Specifications if applicable
Rationale
Wheelchair mounting System
Small/lightweight for carrying by user
Length of use after battery charged
Display viewable in direct sunlight
Recommended Speech Generating Device Code
Based on the patient’s communication needs and considering the patient’s visual, hearing, physical, language and cognitive status as well as specified features as described in this report, SGDs in the ______ Medicare/CPT code category were evaluated to determine the most appropriate SGD to meet the patient’s functional communication goals.
Equipment and Procedures Used in Assessment Speech Generating Devices and Accessories Evaluated The following SGDs and accessories were presented for evaluation. Procedures Used in SGD Trials To assess the patient’s ability to use the selected SGDs the following procedures were used.
Name: 10. DOB:
Outcome of SGD Trials For the following reasons the was selected as the most appropriate SGD for the patient. The other SGDs evaluated were ruled out for the following reasons. Speech Generating Device and Accessories Recommended
The individual's ability to achieve functional communication goals requires the acquisition and use of the SGD, mounting/carrying devices and accessories listed below. This SGD represents the clinically most appropriate device for ( ).
SGD, Mounting System, or Accessory
Medicare/CPT Code
Manufacturer/Vendor
______ ______ ______ ______ ______ ______
Important: Contact family for specifications regarding tubing size for wheelchair mounting system.
Patient/Family Support of Speech Generating Device
The patient’s ________ was present at the evaluation. The ________ was supportive of the patient using the SGD and agreed to the necessity of the SGD for meeting the patient’s communicative needs in activities of daily living.
Physician Involvement Statement
This report was forwarded to the treating physician on . The physician was asked to write a prescription for the recommended SGD and accessories.
VI. TREATMENT PLAN
Following receipt of the recommended SGD and accessories, it is recommended the patient receive of treatment sessions addressing the acquisition of the functional communication goals described in part IV of this report. The patient’s family and/or primary caregivers are encouraged to participate in the treatment sessions so they may learn to assist the patient in the use of the SGD as needed. The patient’s treatment goals would best be met in ______ setting. Following discharge from treatment, the patient will be reevaluated as needed (at
Name: 11. DOB:
the request of the patient, physician, or family) to determine the need for updates/modifications of the SGD.
VII. SLP ASSURANCE OF FINANCIAL INDEPENDENCE AND SIGNATURE
The Speech-Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the supplier of any SGD.
Evaluating SLP name: ASHA Certification #: State License #:
AAC Planning
Tools
Developed by Vicki Clarke, Dynamic Therapy Associates Inc.
AAC Intervention Planning: Schedules AAC User: Meeting Date: Implementation Date:
Type of Schedule: Typical Day Frequent Special Events Infrequent Important Events
Directions: 1st
Column: Write down all activities 2
nd Column: People, Place- Setting
3rd
-7th
Column: Check if activity meets these descriptions
8th
Column: Compare each activity with the others using columns 3-7 and prioritize by importance
9th
Column: List Vocabulary used in this activity- vocab for request, respond, comment,
Pri
ori
ty #
Activity
(ex: get dressed,
watch t.v., pack
backpack, circle time,
lunch...)
Partners/
Environment
(ex: Mom/Kitchen)
Rel
ate
d I
EP
Go
al
#
Incr
ease
s In
dep
end
ence
?
Mo
tiva
tin
g?
Fru
stra
tin
g?
So
cia
lly
Sig
nif
ican
t?
Vocabulary
(messages AAC user might use in this situation,
words needed)
Developed by Vicki Clarke, Dynamic Therapy Associates Inc.
Pri
ori
ty #
Activity Partners/
Environment
Rel
ate
d I
EP
Go
al
#
Incr
ease
s
Ind
epen
den
ce?
Mo
tiva
tin
g?
Fru
stra
tin
g?
So
cia
lly
Sig
nif
ican
t? Vocabulary
Developed by Vicki Clarke, Dynamic Therapy Associates Inc.
AAC Intervention Planning: Vocabulary Customization
AAC User: ____Meeting Date: __________Implementation Date:___________________
List AAC User’s commonly used vocabulary in categories.
Family & Friends Favorite Activities Favorite Characters Toys/Leisure Items
Developed by Vicki Clarke, Dynamic Therapy Associates Inc.
Foods & Drinks ID Info (age, birthday,
address, phone, school, how I
communicate)
Places I Go High Impact Msgs (check all needed)
All done
More
Change it
Something else
You do it
Let me
Like it
Don’t like it
Stop
Hi
Bye
What?
Where?
Wait
Developed by Vicki Clarke, Dynamic Therapy Associates Inc.
Notes: