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[45 CFR 164.520]. A copy of this document (University of Wyoming)

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Page 1 of 8
Updated 1/13/17
Wyoming Institute for Disabilities (WIND)
Wyoming Assistive Technology Resources (WATR)
Department 4298, 1000 University Avenue
Laramie, WY 82071
Phone: (307) 766-6187 Fax: (307) 766-2763
http://www.uwyo.edu/wind/watr watr@uwyo.edu
This project adheres to the Health and Human Services Notice of Privacy Practices for Protected Health
Information,
[45 CFR 164.520]. A copy of this document as well as our institutional policies can be
found on the WAC website at: http://www.uwyo.edu/wind/wac%20at%20assessments/
ASSISTIVE TECHNOLOGY ASSESSMENT REFERRAL FORM
CLIENT/STUDENT INFORMATION
Client/Student Name DOB Age
Address City/ZIP
Phone Referred by
Parent/Guardian/Spouse Name Phone
Therapist Email
Client/WISER ID# Grade/Employer
CONTACT INFORMATION
Person completing this form Date
Address Phone
Relationship to Client E-Mail
Page 2 of 8
Updated 1/13/17
ASSESSMENT NEEDS
Describe the classroom/subject area/type of assignment/skill/activity where the individual is having
trouble:
MEDICAL HISTORY
Medical diagnosis Date of onset
Disability: (check all that apply)
Speech/Language Traumatic Brain Injury
Cognitive Disorder Autism
Learning Disability Other Health Impairment
Hearing Impairment Visual Impairment
Emotional Disturbance Other_____________________
Medical Considerations: (check all that apply)
History of seizures Ear infections
Fatigues easily Swallowing difficulty
Wears glasses Wears hearing aid
Medications - Please list: Has a degenerative condition
Past Hospitalizations (if appropriate)
Date
Reason for hospitalization
When
Is there any additional health information that should be considered during this evaluation?
Page 3 of 8
Updated 1/13/17
CURRENT ASSESSMENT RESULTS
Assessments Attached Results Included Below NA
Area
Name of test
Results : age level,
grade level, etc.
Present Levels of
Performance
Expressive Language
Receptive Language
Cognitive Skills
Reading Skills
Writing Skills
Motor Functioning
Perceptual Functioning
Behavioral/social Skills
Physical Ability Vision/Hearing
Walks Unassisted Date of most recent vision exam
Uses walker/cane Current status
Uses wheelchair Date of most recent hearing exam
Power Manual Current status
Type of chair
If in a wheelchair, has individual had a seating/positioning evaluation? Yes No
Date of seating evaluation
Most reliable motor movements
Turning head Finger movement
Pointing Leg movement
Eye blink Arm movement
Other
Please describe if the individual has any sensory processing difficulties: (e.g. sensitivity to touch/loud
noises, difficulties attending/distractibility)
Page 4 of 8
Updated 1/13/17
COMMUNICATION
Describe individual’s current communication abilities:
Describe a time or example when you feel that the individual’s communication needs were and were
not met: (e.g. time they used their device and with whom)
Does the individual have strong feelings for or against AAC?
How does the individual presently communicate?
At home:
At school/work:
In the community:
Communication Functions:
Check all the functions currently expressed by the individual:
gain attention request adult/peer assistance when needed
express basic wants/needs provide social greetings/farewellls
request activity choices express comments related to an activity
express rejection to an respond appropriately to yes/no questions
undesired item/object/activity respond appropriately to “wh” questions
express recurrence of a desired item/activity
express “finished” to indicate completion of an activity
Page 5 of 8
Updated 1/13/17
Does the individual:
Understand the speech of others Yes___ No___ Comments: _______________________
Understand 1-20 words Yes___ No___ Comments: _______________________
Understand 11-20 words Yes___ No___ Comments: _______________________
Understand more than 20 words Yes___ No___ Comments: _______________________
Understand sentences Yes___ No___ Comments: _______________________
Follow directions Yes___ No___ Comments: _______________________
Make wants known? Yes___ No___ Comments: _______________________
Initiate communication Yes___ No___ Comments: _______________________
Speak in words at times Yes___ No___ Comments: _______________________
Make sounds Yes___ No___ Comments: _______________________
Answer Yes/No questions correctly Yes___ No___ Comments: _______________________
Use facial expressions Yes___ No___ Comments: _______________________
Use gestures/body movements Yes___ No___ Comments: _______________________
Use sign Yes___ No___ Comments: _______________________
Reading/Spelling/Writing
Can the individual:
Read single words Yes___ No___ Comments: _______________________
Read short sentences Yes___ No___ Comments: _______________________
Spell his/her name Yes___ No___ Comments: _______________________
Spell words Yes___ No___ Comments: _______________________
Spell sentences Yes___ No___ Comments: _______________________
Page 6 of 8
Updated 1/13/17
Write letters Yes___ No___ Comments: _______________________
Write name Yes___ No___ Comments: _______________________
Write words Yes___ No___ Comments: _______________________
Write sentences Yes___ No___ Comments: _______________________
Other services individual is currently receiving or has received in the past:
(Example: occupational therapy, speech therapy, physical therapy, adapted PE, counseling)
Therapy
Date(s)
Length
Where
List individuals who need to be included in this AAC consult (or would like to be included):
Name*
Relationship to client
Phone
Email
*Indicate the key staff member(s) who will be present during the assessment/consult
Assistive Technology Systems Currently Used: (check all that apply)
Manual Communication Board
Computer: Type Mac PC
Name operating system used:
With word prediction
With voice output
Page 7 of 8
Updated 1/13/17
Augmentative Communication Device
Name of device # symbols on display
Type of symbols used: objects photos line drawings words/text
How does client access device (make selections)
Environmental Control Unit
Switch: Name of switch
Other:
Past Assistive Technology Use and Outcomes:
Assistive Technology
Length of Time Used/Trialed
Outcome: Did it meet the needs?
EDUCATIONAL/ACADEMIC/VOCATIONAL HISTORY
Current Placement
Birth to 3 High School Hospital
Early Childhood College/University Home
Elementary School Vocational Program
Middle School Nursing Home
Years of school completed
List client’s most recent vocational (job) activities and responsibilities
Position
Responsibilities
Employer
What are the individual’s future educational/vocational goals?
Hobbies/Interests/:
Page 8 of 8
Updated 1/13/17
Dislikes:
What would you most like to gain as a result of this assessment?
CURRENT IFSP/IEP/IPE GOALS AND OUTCOMES
Attached Results below
Please attach any additional information
Assessment Services will be billed through Wyoming Accessibility Center
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