Client name: Client's date of birth: Reason for referral Available government funding source NDIS plan Home care package DS/HACC Continuity of Care funding (+65) None Does the client prefer to use FFS for this referral? Yes No Preferred outcome (if known) e.g. assessment, new wheelchair, transfer docs: Checklist completed by: Relationship to client: Service, location and client address (e.g Support at home - Fig Tree Pocket, 17 Rosella St, Fig Tree Pocket): Who to contact to set appointments (key contact name): Relationship of key contact to client: Key contact details - phone: Please tick which current communication methods are in use: No method Vocalisations Spoken words Signing Symbol boards Communication book Voice output device Other Enter other… How much assistance is required with symbol boards: Please selectNo assistance requiredSet up required Full assistance required How much assistance is required with communication books: Please selectNo assistance requiredSet up required Full assistance required How much assistance is required with voice output devices: Please selectNo assistance requiredSet up required Full assistance required How frequently are vocalisations used: Please selectDailyWeekly OccasionallyNever How frequently are spoken words used: Please selectDailyWeekly OccasionallyNever How frequently is signing used: Please selectDailyWeekly OccasionallyNever How frequently are symbol boards used: Please selectDailyWeekly OccasionallyNever How frequently are communication books used: Please selectDailyWeekly OccasionallyNever How frequently are voice output devices used: Please selectDailyWeekly OccasionallyNever This screening checklist must be filled out in consultation with someone who is familiar with the client’s abilities. It is mandatory to make a referral when any item below has been rated ‘yes’ or when no method of communication is used. Questions 1-2 will be prioritised. Please selectI accept 1. Does the person experience frustration when communicating? Please selectNeverSometimesFrequently 2. Does the person have difficulty using their means of communication e.g. using spoken words, using signs, using pictures/symbols, or device? Please selectYesNo 3. Does the person have difficulty using their communication for a range of purposes e.g. greetings, making choices, asking questions, commenting & describing? Please selectYesNo 4. Does the person have difficulty producing words that are able to be understood? Please selectYesNo 5. Does the person have difficulty following their daily routine? Please selectYesNo 6. Does the person have difficulty understanding what others say? Please selectYesNo 7. Does the person have difficulty following multi-step directions? Please selectYesNo 8. Does the person have difficulty with social skills e.g. taking turns, having a conversation? Please selectYesNo 9. Does the person experience difficulties with fluency e.g. stuttering? Please selectYesNo 10. Does the person have difficulty using an appropriate voice e.g. quality may be husky, breathy, too loud? Please selectYesNo 11. Does the person have difficulty participating in reading activities? Please selectYesNo 12. Does the person have difficulty participating in writing activities? Please selectYesNo 13. Please further describe the issues the person is having: Submit form Leave this field blank
