CHEO Clinic for Augmentative Communication (CAC) Referral Form

About the Clinic for Augmentative Communication (CAC)

CAC may provide communication services to children and youth (0-18 years of age) with limited speech or whose speech is hard to understand to meet daily needs at home and/or who have difficulty producing written work at home. The CAC is designated as an expanded level clinic by the Assistive Devices Program (ADP) and therefore is able to prescribe a range of AAC devices and obtain funding for lease or purchase, as appropriate.

The information on this form will help us determine whether CAC is the most appropriate service to meet the client's needs at this time. Eligibility is based on several factors, including the client's current communication, physical and visual abilities.

Please review eligibility requirements on the CHEO website prior to processing: Clinic for Augmentative Communication - CHEO.

I have reviewed the CAC eligibility requirements on the CHEO website
Consent

I, the referral source, have obtained child/youth/parental/legal guardian consent to complete this referral for CHEO Clinic for augmentative communication (CAC). I have reviewed with the child/youth/parental/legal guardian that the information collected, used, and disclosed will be used to determine eligibility for an assessment at CAC and that this consent can be withdrawn at any time.

Information about the child
Does the child/youth have any of the following diagnoses?

During the day, the child/youth is at (please select all that apply):

School/Daycare information
If the child/youth attends school or daycare, please complete the following information.
Class Placement
Does the legal guardian provide consent for Clinic for Augmentative Communication (CAC) to contact the school/daycare team?
Preferred language for assessment
Interpreter required?
Is the child/youth currently accessing Speech Language Pathology (SLP) services from any of the following agencies:

Speech Language Pathologist
Please provide contact information for the child/youth Speech Language pathologist. Please list all SLPs currently involved with the child.
Does the legal guardian provide consent for CAC to send a referral questionnaire to the child/youth's speech-language pathologist to obtain additional information relating to their communication abilities and needs?
Please select any of the following services the child/youth is currently accessing:

Does the child/youth use any of the following assistive devices for mobility?

Does the child/youth have difficulty hearing?
Does the child/youth have a severe motor or visual impairment that may limit his/her ability to point to symbols with their finger/hand or see symbols?
How does the child/youth express YES or NO?

How is the child/youth communicating?

Is the child/youth intentionally using at least 20 symbols to express themselves (eg. make a choice, request, comment etc.)
Is the child/youth combining symbols together? E.g. more music, go park, eat cracker, all done cars
Is the child/youth using verbal/spoken words?
If you selected yes, please note the approximate percentage of speech understood by familiar communication partners:
If you selected yes, please note the approximate percentage of speech understood by unfamiliar communication partners:
Is the child/youth able to spell/write? E.g. Spell their name, simple words (e.g. cat, mom/dad), short phrases or longer sentences?
Does the child/youth receive any funding?


MyChart: Visit our MyChart webpage and fill out the MyChart Access Request Form

If you have a question about this form, please contact 613.737.2757 or 1.800.565.4839
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