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This referral form should be completed for children and young people who will meet the criteria for a specialist Augmentative and Alternative Communication (AAC) service intervention.

An individual who would access a specialist AAC service would: Have a severe or complex communication difficulty associated with a range of physical,

cognitive, learning or sensory deficits. Have a clear discrepancy between their level of understanding and ability to speak. Be able to understand the purpose of a communication aid. Have developed beyond cause and effect understanding.

And may:

Have experience of using a low tech AAC device which is insufficient to enable them to realise their communicative potential.

The Kent and Medway CAT Service is jointly commissioned to support children and young people with SEN who have complex written communication difficulties. For this reason our criteria can also include children and young people who:

Have complex physical difficulties which mean standard methods of accessing computers are not effective and appropriate and require a specialist approach.

Require advice, for example regarding their progression in Assistive Technology (AT) use where appropriate curriculum software and alternative computer access devices have been trialled and evaluated.

Require involvement to introduce technologies associated with alternative means of recording.

Referrals will be accepted from health, education and social care professionals working in local teams. The forms are of most use when completed by the team around the child or young person and their family.

Please keep information concise, key points are sufficient and attach additional pages where necessary.

This form should be completed electronically, if you require this form in alternative format or for assistance, please contact us.

Section 1: 1.1 Parental Responsibility, Consent and Mental Capacity:

Parental Responsibility:Please give details of all people with legal parental responsibility and ensure their contact information has been provided in section 2.4

Name: Relationship:

Name: Relationship:

Parental responsibility may be shared between a number of people beyond the child or young person’s natural parents; such as step parent, social worker or legal guardian. Please give details of any additional person with legal parental responsibility:

Name: Relationship:

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Kent and Medway Communication and Assistive Technology Service (KM CAT)

Referral Form

Parental Responsibility (continued):The Kent and Medway CAT Service includes professionals from a number of different organisations. In order to work together effectively, we need to collect and share information. We will all ensure that your information is processed fairly and lawfully in line with the Data Protection Act 1998.

I have read this completed referral form and agree to the sharing of information between all practitioners and agencies in relation to all aspects of this process.

I understand that this referral is the first stage in the application process for support from the Kent and Medway CAT Service. The submission of this form does not guarantee that support will be provided.

Signed: Print: Date:

Head Teacher Consent:If the Kent and Medway CAT service provides support, then I understand that the school will need to provide the child or young person with equipment and ongoing human resources. There will need to be a plan for this specialist intervention within the individual’s provision plan. For example, teaching assistant time or technical support.

I understand that this will need to include a minimum of an individual education programme (or relevant individual targets) and should include one or more of the following:

Use of specialised hardware and software. Keyboarding skills. Highly differentiated Literacy and Numeracy programmes at an appropriate developmental

level. Personal care and independence skills. Highly differentiated Speaking and Listening skills programme. Learning environments where individual communication modes (for example PECS, signing,

symbols, PODD and so on) are actively supported and developed. Support available to implement individual therapy programme(s) to address language skills as

advised by therapists. CPD arrangements for training in AAC and AT systems.

Signed: Print: Date:

Please note: In order to process the referral, we must have consent from parents (or legal guardian) and the Head Teacher from the child or young person’s educational

setting.

Mental Capacity (for young people over the age of 16 years old):Please demonstrate that under the Mental Capacity Act (MCA) you are making this referral in the best interests of the child or young person.

Has the child or young person consented to this referral?

☐ Yes ☐ No

If no, please attach a copy of the completed MCA assessment and state the reasons why this referral is in the child or young person’s best interests.

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Section 2:

2.1 The Child or Young Person:

Surname: Date of Birth:

First name: Age: years months

NHS No: KCC UPN: School Year:

2.2 Parent or Guardian:

Parent/Guardian Name 1: Parent/Guardian Name 2:

Home Address: Home Address:

Home Postcode: Home Postcode:

Home Phone: Home Phone:

Mobile Phone: Mobile Phone:

Name of referrer: Role:

Email: Phone:

Address:

Signature: Date:

2.3 Referrer:

2.4 Other Person(s) completing this request form, including the contact details of anyone listed in section 1.1:

Name Role Phone number Email Base

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2.5 School Information:

School: School Key Contact:

School Address:

School Postcode: School Phone:

Section 3:

3.1 What do parents or carers expect to see happen as a result of this referral?

Is the child or young person educated at: Type of School:

☐ School ☐ Pre-School ☐ Primary

☐ Home ☐ Mainstream ☐ Secondary

☐ Special School ☐ Further Education

3.2 What tasks does the school expect this child or young person to be able to do using AAC and AT that is currently difficult for them to achieve?

3.3 What tells you that the child or young person is ready to benefit from AAC or AT?

Please include their views if they have means to show what they want to change

3.4 Please summarise the current level of involvement of support services: of 18 20151101

Person 1 Person 2 Person 3 Person 4 Person 5

Name of person and support service?

What support are you currently providing?

What is the focus of this intervention?

What is the frequency of involvement planned for the next 12 months?

Is a recent report or programme of intervention enclosed with the referral?

Person 1 Person 2 Person 3 Person 4 Person 5

Has this person contributed to sections of this referral information?

The purpose of attaching recent reports is to enable us to make an informed decision about the relevance of our service for this child or young person.

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Section 4: 4.1 In this section, please tick all that apply in terms of the child or young person’s disability or limiting condition (including any mobility issues):

☐ Cerebral Palsy ☐ Dyslexia☐ Hemiplegia ☐ Degenerative condition☐ Learning difficulties ☐ Hearing Impairment☐ Acquired Brain Injury ☐ Visual Impairment☐ Emotional/behavioural difficulties ☐ Orthopaedic Impairment (Specify below)☐ Significant developmental delay ☐ Verbal Dyspraxia☐ Epilepsy ☐ Autistic Spectrum Disorder☐ Dyspraxia ☐ Specific Language Impairment (SLI)☐ Neurological disorder ☐ Speech and language difficulties☐ Sensory processing disorder ☐ Other

Any other specific diagnosis or additional comments:

4.2 Has the child or young person previously had a consultation with the Kent and Medway CAT service? If so, please evaluate the results of the recommended actions. If any recommended actions have not have not been carried out, please explain why.

4.3 In this section, please give details of any fine motor difficulties that the child or young person experiences. Please note the term ‘fine motor’ refers to the co-ordination of the smaller movements of the hands and fingers. Please comment on how the child or young person uses both arms and hands to perform everyday activities. Please indicate if and how their fine motor ability limits or impacts on their daily function.

For example, please describe how they hold and use writing tools, including how much physical effort is required. Please include information from an Occupational Therapist, especially regarding handwriting (including any timed handwriting assessments) and keyboard skills, if available.

4.4 In this section, please tick all that apply in terms of gross motor difficulties that the child or young person experiences. Please note the term ‘gross motor’ refers to the co-ordination of large muscle groups and whole body movements, including movement and control of the head, legs and arms.

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☐ Limitations in range of movement (RoM)☐ Unintegrated reflexes or abnormal muscle tone☐ Difficulty with accuracy of movement☐ Do they use mobility aids?

4.5 In this section, please give details of any sensory difficulties that the child or young person experiences. Please note the term ‘sensory’ refers to hearing, visual abilities and sensory processing needs. Does the pupil have any known sensory processing difficulties?

If yes, please explain how this impacts on their daily function and engagement, and provide information about any behavioural strategies used.

If the child or young person is operating at ‘P’ levels or if there is evidence of significant delay in areas of Literacy, Numeracy, Language Comprehension and Expressive Language; please complete all sections of the profiles in sections 5, 6 and 7. If the child or young person is operating at ‘NC’ levels, please complete sections 6 and 7 only.

Section 5:

5.1 Numeracy (Please tick all that apply):

☐ Engages in joint attention with adult(for example, number songs, stories, games)

☐ Can indicate ‘one’ or ‘two’

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☐ Shows an interest in number activities withadults

☐ Joins in rote counting to 5

☐ Shows awareness of number activities andcounting rhymes and songs

☐ Makes sets of up to 3

☐ Follows a sequence of pictures or numbers ☐ Joins in rote counting to 10

☐ Joins in with familiar number rhymes, songsand games

☐ Recognises numerals from 1 to 5

☐ Shows awareness of contrasting quantities(for example, ‘one’ and ‘lots’)

☐ Joins in rote counting beyond 10

☐ Understands one-one correspondence(for example, matching cups to saucers)

☐ Continues to rote count onwards from a given small number

☐ Demonstrates an understanding of ‘more’(for example, more cups are needed)

☐ Recognises numerals from 1 to 9 and relates them to sets of objects

☐ Demonstrates an understanding of ‘less’(for example, which bottle has less water)

☐ Understands ordinal numbers (first,second, third)

☐ Picks out described shapes from a collection ☐ Estimates a small number up to 10

☐ Recognises differences in quantity(for example, which group has more or less)

☐ In practical situations, can respond to ‘add one’ or ‘take away one’

Please summarise how the child or young person demonstrates the skills listed in Section 5.1. For example, this could be by verbalising, writing, typing, pointing to flash cards, eye pointing using an E-tran frame, using a switch to scan and select.

If the child or young person is making a selection, for example from cards on an E-tran frame, please state how many choices are presented and how much support is given. For example they can identify which number comes ‘next’ in a given sequence by eye-pointing to the correct number from a choice of 4.

Please summarise how the child or young person joins in with number rhymes and so on. For example, this could be verbally, signing, using gestures.

5.2 Literacy (Please tick all that apply):

☐ Engages in joint attention with adult(for example, songs, stories, games)

☐ Writes (or types) emergently

☐ Shows an interest in books and storieswith adults

☐ Can trace, overwrite, copy or replicateshapes and straight line patterns

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☐ Understands how books work(for example, can hold book the right way up)

☐ Produces their name in letters by copying

☐ Shows an interest in looking at booksindependently

☐ Copy letter forms to create labels orcaptions and so on

☐ Associates pictures with spoken wordswhen being read to

☐ When asked to spell a word, gets firstphoneme correct

☐ Realises text conveys meaning ☐ When asked to spell a word, gets firstand last phoneme correct

☐ Recognises connection between spokenwords and specific text when read to

☐ Makes phonetically plausible attempts atspelling words

☐ Recognises environmental print, ☐ Can spell words with some accuracy

☐ Matches letters and short words ☐ Can produce single key words (for example, their name).

☐ Predicts elements of a narrative (for example, what comes next)

☐ Can produce other single words

☐ Understands conventions of reading (for example, following text from left to right).

☐ Groups letters and leaves spaces between them as though writing words

☐ Applies phonic rules when attempting to decode words

☐ Forms short phrases

☐ Blends sounds to make words ☐ Can produce sentences☐ Reads a number of familiar words or

symbols☐ Recognises at least half the letters of the

alphabet by shape, name or sound

Please summarise how the child or young person demonstrates the skills listed in Section 5.2. For example, this could be by writing, typing, pointing to flash cards, eye pointing on an E-tran frame, using a switch to scan and select.

If the child or young person is making a selection, for example from letters on an alphabet board, please state how many choices are presented and how much support is given. For example, they can spell a word by pointing to each letter, from a choice of 8.

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Section 6:

Summary of student’s abilities and concerns related to numeracy:

Summary of student’s abilities and concerns related to literacy:

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Section 7:7.1 Comprehension (Please tick all that apply):

☐ Reacts to a range of people, familiar and unfamiliar

☐ Recognises some objects

☐ Reacts when sees familiar objects ☐ Recognises some photos☐ Reacts when people speak ☐ Recognises some pictures☐ Shows anticipation of a familiar activity or

event☐ Recognises some symbols

☐ Reacts to new experiences and activities ☐ Can sort objects into categories

☐ Reacts to own name ☐ Can sort symbols into categories☐ Demonstrates understanding of names of

familiar or motivating objects or activities☐ Can point or look to tell or label, for

example ‘Where’s the dog?’

☐ Demonstrates understanding of names of familiar people

☐ Can match object to object

☐ Shares an activity with someone else ☐ Can match symbol/picture topicture/symbol

☐ Understands what they do has an impact ☐ Can match object to symbol or picture

☐ Demonstrates an awareness of others ☐ Demonstrates understanding of causeand effect

☐ Reacts to changes in tone of voice, facial expression and body language

☐ Recognises some signs

☐ Tracks sounds or visually interesting objects

Is the child or young person able to:

☐ Understand sentences with 2 information carrying words

If applicable, please give an example:

☐ Understand sentences with 3 information carrying words


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☐ Understand some prepositions


☐ Understand some negatives


☐ Understand some questions


Please summarise how the child or young person demonstrates the skills listed in Section 7.1. For example, summarise an activity where you are confident the child or young person understands the meaning of the language used.

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Do they rely on this being a regular event or do they also understand the language in a new activity?

How much support do they need from signs or objects or pictures or symbols; do they understand the signs or objects or pictures or symbols when you do not say the word when showing the objects or picture or symbol?

How do you know that they understand the language or the representation of (object, picture or symbol)?

Does the child or young person demonstrate their understanding with facial expression, gesture, body language, yes or no response, pointing, eye pointing?

Which sign and which symbol system does the child understand?

7.2 Expressive (please tick all that apply)

☐ Shows intent to communicate by looking at, reaching for or touching

☐ Uses objects to communicate

☐ Can hold gaze on a person or object inquestion

☐ Uses pictures/photos to communicate

☐ Moves gaze or attention between person and object in question

☐ Uses symbols to communicate

☐ Shows pleasure when communicationattempt is successful

☐ Uses written words to communicate,relies on the communication partner saying the words as they show or point to the object, picture, photo or symbol☐ Shows displeasure when communication

attempt is not successful

☐ Can initiate interaction ☐ A non-preferred/don’t like/blank offeredalongside

☐ Can sustain interaction ☐ Can communicate spontaneously☐ Motivated to communicate ☐ Can combine symbols with prompt☐ Consistent yes response ☐ Can combine symbols without prompt☐ Consistent no response ☐ Uses communication book

(please include example pages with this referral)

☐ Can communicate clear likes and dislikes

☐ Able to use some signs ☐ Can gain attention☐ Can look at ‘empty hands’ with different

labels for choicesIs the child or young person also able to:

☐ Use single symbols.

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If so, how are these presented, how many at a time, how big?

☐ Use vocalisations

If so, please give examples and describe what they mean.

☐ Use speech.

If so, please give examples of spoken words. How easily are they understood by unfamiliar people?

Which of the following language functions does the child or young person use? (Please tick all boxes that apply):

☐ Expresses wants ☐ Expresses likes☐ Expresses dislikes ☐ Requests something☐ Greets ☐ Requests more☐ Gives information ☐ Describes something or someone☐ Directs person or activity ☐ Asks questions☐ Comments ☐ Repairs misunderstandings☐ Reasons or negotiates ☐ Expresses feelings

Please summarise how the child or young person demonstrates the skills listed in Section 7.2. For example, this could be by pointing, touching, eye pointing.

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Are unfamiliar communication partners able to understand the child or young person’s communication? Which sign and which symbol system does the child or young person use?

Please give an example of when, where, with whom and about what the child or young person is best at communication.

Any Additional Information:

Section 8:

8.1 Please give details and evaluation of resources used for communication and curriculum access, both in the past and currently.

Resource(specify what, where used, what for)

Used previously Summarise how this is being used currently

Paper or low tech communication book, boards or activity sheets

Low tech writing aids (for example adapted pencils or a writing slope)

Computer, laptop, tablet or other electronic device.

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Light tech digital speech output (for example, Go Talk)

Speech recognition (for computer or tablet) software

Free iPad or tablet based resources that are non-customisable

Other iPad/tablet based resources that have been customised for the child or young person

Word Prediction

Curriculum software (for example, Clicker or ChooseIt)

Alternative access, for example joystick, adapted mouse or switches

Access settings on computer hardware, for example filter keys or onscreen keyboard

Uses a keyboard for computer access. If so, please describe typing skills from the following options. For example:

touch types fast or slow, one or two hands;

‘hunt and peck’, fast or slow, one or two hands,

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touchscreen

Scribe

8.2 Please tick what paperwork you have enclosed with this form. We expect a minimum of the Statement of SEN or Education, Health Care (EHC) plans.

☐ Most relevant and recent Annual Review paperwork ☐ Provision map☐ Statement of SEN or EHC plan, including current targets ☐ School Report

Date of Statement of SEN or EHC Plan:

Please return this form to:Kent and Medway CAT Service

The Old Railway SchoolWainwright Place

NewtownAshford

KentTN24 0PF

Tel: 01233 629859

Client Ethnicity

Please Tick

Please Tick

White A British ☐ Asian H Indian ☐

B Irish ☐ J Pakistani ☐

C Any other white background

☐ K Bangladeshi ☐

L Any other Asian

background

☐

Mixed D White and Black Caribbean

☐

Black or Black British

M Caribbean ☐

E White and Black African

☐ N African ☐

P Any other Black background

☐

F White Asian ☐

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G Any other mixed background

☐

Other Ethnic

R Chinese ☐

S Any other ethnic category

☐

Pupil Asked

Z Pupil asked but declined

☐

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