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I have read the AAC at Heartspring document
If so, do you have any questions regarding the document?
* Child's Name:
* Parent/guardian Name:
Date of Birth:
Onset of Medical Condition/Diagnosis:
If yes, type and frequency:
Is hearing normal?
Date of last screening:
Is vision normal?
Describe any other significant concerns:
Does the child have any motor movement challenges?
If so, please describe:
Isolates finger and points?
Please list any special equipment used for gross or fine motor activities:
Does the child initiate communication interactions?
Does the child respond to communication interactions?
Approximately how intelligible is the child to unfamiliar listeners?
Approximately how intelligible is the child to familiar listeners?
Does the child demonstrate frustration when he/she is not understood?
If yes, how?
Forms of communication used by child (please check all that apply and list examples of each):
If child uses pictures, what format?
Has an augmentative and alternative evaluation ever been completed in the past?
If yes, please provide name and contact info for evaluator:
Date of Evaluation:
Has any type of augmentative or alternative communication been used or recommended in the past?
If yes, what?
What is the child's primary mode of communication at home?
What is the child's primary mode of communication at school?
Responds to speaker:
Understands what is said to him/her:
Follows simple directions:
Follows complex, multi-step directions:
Can group similar items together (e.g. clothes, food):
Does the child understand more than he/she is able to communicate?
Describe child's reading skills:
What do you feel are the most important communication needs at home?
What do you feel are the most important communication needs in school/community?
What are some of your child's favorite things or activities? (examples include specific foods, music, people, activities, toys, games, places, etc)
Please describe any behaviors you feel might be significant for this evaluation:
Please estimate attending skills for structured tasks (ex. can stay on task 5, 10, 15 min, etc):
Please include any additional information you feel would be helpful:
Name of person completing this form:
Relationship to client:
What questions would you like addressed during this evaluation?
Please upload any pertinent reports or paperwork (e.g. IEPS, Speech/OT/PT or Psych evaluations).