Augmentative Communication Evaluation
Preliminary Questionnaire

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    690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296  ||  Phone: (480) 590-2098  ||  Fax: (480) 820-0462

    Patient Information



           Is Texting Ok?  YesNo

    Has the patient used AAC in the past or is currently using an AAC device?  YesNo

    Academic History



    Does the evaluation team/ training therapists have your permission to contact the school personnel to collaborate prior to the evaluation and schedule training sessions (if applicable) after the device is purchased?  YesNo

    Fine Motor

    Can the patient pick up and hold a cup?  YesNo

    Can the patient pick up and hold a cookie?  YesNo

    Can the patient pick up and hold a raisin?  YesNo

    Can the patient point and press buttons on a cell phone/tablet?  YesNo

    Does the patient typically throw things in frustration or anger?  YesNo


    Does the patient try to communicate verbally?  YesNo

    Does the patient show frustration because he/she is unable to communicate?  YesNo

    Does the patient follow simple commands?  YesNo

    Does the patient answer yes/no questions?  YesNo

    Behavioral Concerns

    Does the patient have a behavioral plan or need behavioral therapy?  YesNo

    Functional Mobility

    Does the patient walk independently?  YesNo

    Does the patient use a wheelchair?  YesNo

    Hearing and Vision

    Does the patient have a hearing loss?  YesNo

    Does the patient have any vision problems?  YesNo

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    Advanced Therapy Solutions
    690 E Warner Road #105
    Gilbert, AZ 85296

    Office Phone: 480.820.6366
    Office Fax: 480.820.0462

    Hours of Operation:
    Monday to Friday
    8:00am to 4:00pm