Kent Communication & Assistive Technology Service The Old Railway School Wainwright Place Newtown Ashford Kent TN24 0PF Tel: 01233 629859 Fax: 01233 639516

Referral Form

Before completing this form, please look at Section 8 for the KM CAT Service Criteria and Guidance and the Glossary of Terms. If you are referring for complex access support only, you do not need to complete section 4.

Section 1:

The Child or Young Person / CYP:

First name:	Last name:
NHS No:	KCC UPN:
Date of Birth:	Age:	years	months	School Year:

CYP’s Address:

Home Address:	Adults living at this address with Parental Responsibility for the CYP
Name	Relationship	Phone Number
Postcode:
Phone:

Parental Responsibility:

Parental responsibility may be shared between a number of people beyond the child or young person’s (CYP) natural parents. This could be a step parent, legal guardian, social worker or a parent who is not living at the CYP’s main contact address. Please give details of any additional person with legal parental responsibility.

Name:	Name:
Relationship to CYP:	Relationship to CYP:
Address:	Address:
Postcode:	Postcode:
Phone:	Phone:

Social Worker Details: (if different to those listed above)

Name:	Phone:
Address:	Mobile:
Postcode:	Email:

Other Information: (For example, information required in an alternative format or language)

CYP	Parent/Carer
First Language:
Other Languages:
Alternative Format:

Education Provision:

Please give details of both placements, if the CYP has a split placement across two provisions.

Provision one:

Provision Name:	Key Contact:
Address:
Postcode:	Phone:
☐	Pre-School	☐	Specialist Resource Provision (SRP)
☐	Special School	☐	Mainstream Secondary School
☐	Mainstream Primary School	☐	Further Education Provision (FE)
☐	Home Educated with an Educational Health and Care Plan in place

Provision two:

Provision Name:	Key Contact:
Address:
Postcode:	Phone:
☐	Pre-School	☐	Specialist Resource Provision (SRP)
☐	Special School	☐	Mainstream Secondary School
☐	Mainstream Primary School	☐	Further Education Provision (FE)
☐	Home Educated with an Educational Health and Care Plan in place

Diagnosis and Medical Details:

Please provide full details about the CYP’s GP, main diagnoses, conditions, concerns and anything currently being investigated. Include any aids that are used and assessments that have been completed by other services.

GP Practice Name:	GP Address:
Main Diagnosis:
Other Conditions:
Current Medications:
Vision:
Visual Perception:
Hearing:

Previous Referral:

Did they have a consultation with KM CAT? If so, please evaluate the results of the recommended actions. If any recommended actions have not been carried out, please explain why.

Section 2: Professionals Involved

Referrers:

We would like to have two named professionals referring the CYP to KM CAT, ideally an Education and a Health Professional. Please contact the KM CAT team if this is not possible.

Lead Referrer:	Role:
Email:
Address:
Postcode:	Phone:

Second Referrer:	Role:
Email:
Address:
Postcode:	Phone:

Other Professionals Involved with CYP:

Name:	Role:	Is this professional aware of referral? Yes ☐ No ☐
Email:
Address:	Should this professional be invited to assessment? Yes ☐ No ☐
Postcode:	Phone:
Name:	Role:	Is this professional aware of referral? Yes ☐ No ☐
Email:
Address:	Should this professional be invited to assessment? Yes ☐ No ☐
Postcode:	Phone:
Name:	Role:	Is this professional aware of referral? Yes ☐ No ☐
Email:
Address:	Should this professional be invited to assessment? Yes ☐ No ☐
Postcode:	Phone:
Name:	Role:	Is this professional aware of referral? Yes ☐ No ☐
Email:
Address:	Should this professional be invited to assessment? Yes ☐ No ☐
Postcode:	Phone:

Section 3: Aspirations

3.1 Parents and Carers:

What do Parents and/or Carers expect to see happen as a result of this referral?

The Child or Young Person:

The opinion of the CYP is important to us and we would like to have their views, if possible. If they are 16 or over their views must be included, unless they do not have the capacity to contribute (see section 7). Is the CYP aware of this referral, and if so, what do they wish to happen as a result of this referral?

Referrers:

What do the referrers expect to see happen as a result of this referral?

Additional Information:

Is there any additional information about the CYP that you think the KM CAT would need to know about?

Section 4: Existing and Previous use of Communication Aids

Low tech communication: (paper based resource)

Please describe the low tech communication aids (including details of communication charts or books), symbol sets, number of pages, number of symbols per page, structure and format. Please include information about the mixture of core and fringe vocabulary, frequency and situations it has been used in, if it met their needs and if not, why not?

Light tech communication: (battery powered resources)

Please describe the light tech communication aids that have been used, for example a BIGmack or Go Talk. Also, please include the symbol layout used, frequency and situations it has been used in, if it met their needs and if not, why not?

High tech communication: (mains powered devices)

Please describe if the CYP has experience of using high tech communication aids and if so, please specify type of device, which apps or vocabulary packages, how long the CYP has been using High Tech, how often and situations it has been used in, if it met their needs and if not, why not?

Evidence of benefit:

What evidence is there to indicate that the CYP is ready to benefit from more specialist AAC or AT provision, please include their views and what they would like to change?

Functions of Language

Please give specific examples of what the CYP has communicated, for all functions of language that apply, including using verbal or non-verbal means.

Functions of Language	Examples, include frequency (never, always, sometimes….)
Makes a request for something, somewhere, action, more or help
Greets
Gives information
Describes something or someone
Directs a person or activity
Asks questions
Comments
Repairs misunderstandings
Reasons or negotiates
Expresses feelings

Receptive Language (Please tick all that apply):

☐	Shows anticipation of a familiar activity or event	☐	Recognises some signs, for example Makaton
☐	Shares an activity with someone else	☐	Recognises some symbols, photos or pictures
☐	Will look or point to a named object from a choice of four or more	☐	Shows understanding beyond the here and now
☐	Looks or waits for a response after attempting to communicate	☐	Can sort objects/symbols into categories

Please give examples of the CYP’s receptive language, with familiar and unfamiliar communication partners and in a range of contexts.

Please give results of any assessments of receptive language. For example, word level, understanding of concepts such as big and little, prepositions and questions.

What strategies support the CYP’s receptive language? For example, face-to-face, Makaton signs, visual timetables, symbols?

Expressive Language (Please tick all that apply):

☐	Shows intent to communicate by looking at, reaching for or touching	☐	Shows displeasure when communication attempt is not successful
☐	Can gain attention	☐	Consistent no response
☐	Consistent yes response	☐	Can combine symbols with prompt
☐	Can initiate interaction	☐	Can combine symbols without prompt
☐	Uses text to communicate	☐	Motivated to communicate (without prompting) different functions, beyond requesting

When the CYP makes a choice, how many options are presented and is a non-preferred or a blank symbol offered?

Does the CYP have any speech or vocalisations? If so, are these understood and by whom?

If the CYP uses signing, what system do they use and please provide examples of how they use signs?

Section 5: Education

Current Attainment:

Literacy Levels	Numeracy Levels
☐	Above age expected level	☐	Above age expected level
☐	At age expected level	☐	At age expected level
☐	Below age expected level	☐	Below age expected level
☐	Well below age expected level	☐	Well below age expected level
Is the child making progress?	Is the child making progress?
☐	Yes	☐	Yes
☐	Small Steps of Progress	☐	Small Steps of Progress
☐	No	☐	No

Current EHCP and Provision Plan Outcomes (if applicable)

Please tick to show priority level for each outcome:

Communication and Interaction: Priority	1	☐	2	☐	3	☐	4	☐

Cognition and Learning: Priority	1	☐	2	☐	3	☐	4	☐

Social, Emotional and Mental Health: Priority	1	☐	2	☐	3	☐	4	☐

Sensory and/or Physical: Priority	1	☐	2	☐	3	☐	4	☐

Cognition: Concentration / Memory / Processing skills

Please outline any concerns or relevant information that you may have around the CYP’s cognition. Include the strategies that have been used to support them and how successful the strategies have been. Also, if the CYP has been given a task, do they need support, visual prompt, verbal repetition or a task management board?

Literacy (Please tick all that apply)

☐	When asked to spell a word, gets first phoneme correct	☐	Makes phonetically plausible attempts at spelling words
☐	Recognises at least half the letters of the alphabet by shape, name or sound	☐	Reads a number of familiar words or symbols
☐	Writes (or types) emergently	☐	Can spell a variety of words by sight
☐	Can spell words with some accuracy	☐	Can produce sentences

Please summarise how the CYP demonstrates the skills listed above. This could be by writing, typing, pointing to flash cards, eye pointing on an E-tran frame or using a switch to scan and select. If the CYP is making a selection, such as 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.

Summary of strengths related to literacy:	Summary of concerns related to literacy:

Please confirm that you have enclosed the following paperwork with this form:

☐	Education, Health and Care Plan	☐	Provision Plan
☐	School Report	☐	Relevant Therapy Reports

Section 6: Physical and Sensory Skills, Posture and Seating

Gross Motor Function

Please describe the main physical factors that affect the CYP’s functional ability, for example tremor, tone, head and trunk control. Please also include the CYP’s GMFCS score, where applicable.

Fine Motor Function

Please describe the CYP’s upper limb control and hand function. For example, are they able to isolate a finger, what size item can they point to or press with accuracy, including icons on an iPad or typing on a keyboard. Please also include the CYP’s MACS score, where available.

Is the CYP:	Right handed	☐	Left handed	☐	No hand dominance	☐

Mobility

Please describe the CYP’s indoor and outdoor mobility, including information on any equipment provision they may use in different environments.

Seating and Positioning

List any equipment used by the CYP at home and at school. Please give a brief description of postural accessories currently used, for example, pelvic or lap straps, pommels, thigh guides.

Sensory Processing Difficulties

Please explain if the CYP has any known sensory related challenges. For example, is movement seeking or has sensitivities to sensory input (such as noise) or difficulties with regulation. Please explain how this impacts on their daily function and engagement, providing information about any sensory or behavioural strategies used.

Alternative Access and Recording; low tech writing support and adaptations trialled and used

Please explain if the CYP has trialled or uses items such as adapted pencils, writing slope, or a scribe. Please give an indication of any challenges the CYP has in completing written tasks including keeping up in class, getting work finished in time, legibility of writing. Explain if and why this system is not meeting the CYP’s needs.

Hardware trialled and used

Please state the different hardware the CYP has tried. For example, PC, laptop, tablet or iPad, ability to access Interactive Whiteboard. Please give an indication of what these are used for, such as recording, leisure, searching internet, using Apps. Include if and why this system is not meeting the CYP’s needs.

6.8 Alternative Recording skills

If the CYP uses an iPad, laptop or PC for alternative recording, please indicate type of keyboard used and describe their typing skills and ability. For example, one or two hands, fast or slow and if they are accurate.

Software trialled and used

Please state any software that the CYP has used or trialled. For example, speech recognition software, word prediction, e-reader, curriculum software (such as, Clicker or DocsPlus). Include details of access settings used, for instance, onscreen keyboard, filter keys and any accessibility options.

Complex access relates to the CYP having complex physical difficulties which mean standard methods of accessing technology are not effective or appropriate and require a specialist approach.

Does the CYP have complex access needs?	Yes	☐	No	☐

Section 7: Consent

7.1 Parental Responsibility

By signing this referral, I confirm that:

I have read this completed referral form and agree to the points outlined in the KM CAT Partnership Agreement Document (CAT-CR-02). I understand 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:

For young people aged 16 or over:

7.2 Mental Capacity

Has the young person (or parent/guardian) consented to this referral?	Yes	☐	No	☐
Where appropriate, has an MCA Assessment been carried out, in accordance with the MCA (2005)?	Yes	☐	No	☐

7.3 Lead Referrer

By signing this referral, I confirm that:

I have read this completed referral form and agree to the points outlined in the KM CAT Partnership Agreement Document (CAT-CR-02).
Signed:	Print:	Date:

7.4 Second Referrer

By signing this referral, I confirm that:

I have read this completed referral form and agree to the points outlined in the KM CAT Partnership Agreement Document (CAT-CR-02).
Signed:	Print:	Date:

7.5 Head Teacher Consent:

By signing this referral, I confirm that:

I have read this completed referral form and agree to the points outlined in the KM CAT Partnership Agreement Document (CAT-CR-02).
Signed:	Print:	Date:

Data Protection:

We will ensure that your information is processed fairly and lawfully in line with the current Data Protection legislation. For more information and the GDPR privacy statement, please go to: www.kent.gov.uk/privacy and follow the link to Education: SEND.

Please return this form to:

The Kent and Medway Communications and Assistive Technology (KM CAT) Service

The Old Railway School | Wainwright Place | Ashford | TN24 0PF

kentcatadmin@kent.gov.uk | kcht.cat-admin@nhs.net

Section 8: Guidance on Completing the KM CAT Referral Form

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 CYP and their family. Where the team around the CYP has jointly completed the form, it gives the best information in order to consider whether the referral criteria is met.

Referrals may result in a CYP being offered a complex assessment, a one-off consultation, or signposting to other services.

In order for a CYP to be offered a complex assessment, they will need to meet the NHS England Criteria for referral to a specialised AAC service. This criteria states that a complex assessment for communication can be offered to a CYP who:

Has a severe or complex communication difficulty associated with a range of physical, cognitive, learning or sensory deficits.

Has a clear discrepancy between their level of understanding and ability to speak.

Is able to understand the purpose of a communication aid.

Has 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.

More information can be found in the document “Guidance for Commissioning AAC Services and Equipment”, published March 2016. www.england.nhs.uk

If a CYP is on their way to meeting this criteria, but needs further support at a local level before they meet the full NHSE England criteria, then a one-off consultation may be offered to give guidance on next steps.

Additionally, for CYP who have education provided within the Kent County Council (KCC) boundary, or have a KCC EHCP, KCC commission the KM CAT service to support CYP who have complex written communication difficulties. This criteria states that a complex assessment for access can be offered to a CYP in Kent who:

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

Requires 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.

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

If you require this form in alternative format or for assistance, please contact us.

Referral to KM CAT Process

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 and Asian	☐
G	Any other Mixed background	☐
Other Ethnic	R	Chinese	☐
S	Any other Ethnic category	☐
Pupil Asked	Z	Pupil asked but declined	☐