Communication Assessment

Client:

QIDP:

Date:
PRIMARY M EANS OF COMMUNICATION

Verbal

 Written

 Behavioral Cues

 Picture Systems

 Sign Language/Gestures

 Communication Device

 Other:

OTHER MEANS OF COMMUNICATION

 Verbal

 Written

Behavioral Cues

 Vocal Cues (volume and inflection)

 Picture Systems

 Sign Language/ Gestures

 Communication Device

 Other:

ATTENTION SPAN

Attends tasks 15 minutes without supervision

 Attends tasks 15 minutes with supervision

 Attends tasks 5 minutes without supervision

 Attends tasks 5 minutes with supervision

 Attends tasks for less than 5 minutes, with or without supervision

Verbal Communication Assessment

ALWAYS SOMETIMES RARELY NEVER

 Initiates verbal
interactions
Verbalizes simple words
Speaks in full sentences
Speaks clearly and
understandably
Establishes eye contact
during verbal
communication
Reacts differently to
gentle verses assertive
voice
Can verbally indicate
wants and needs
Can verbally indicate
personal choice
Can verbally indicate
medical concerns
Can verbally indicate
emotional states
Can verbally indicate
personal or emergency
information
Repeats others’
statements
Verbally agrees with
others’ statements
Verbally disagrees with
others’ statements
Follows 1 step verbal
directions
Follows multi- step verbal
directions

SIGN/ G ESTURES Communication Assessment

ALWAYS SOMETIMES RARELY NEVER

Initiates interactions using
gestures
Establishes eye contact
during gestured
communication
Uses gestures (sign) to
indicate wants and needs
Uses gestures (sign) to
indicate personal choice
Uses gestures (sign) to
indicate medical concerns
 Uses gestures (sign) to
indicate emotional states
Uses gestures (sign) to
communicate personal or
emergency information
Uses American sign
language (ASL) as
primary language
Uses some ASL signs
Uses self-made
or pigeon sign language
Mimics message
sender’s signs or
gestures
Follows 1 step gestured
directions
Follows multi-step
gestured directions

WRITTEN COMMUNICATION ASSESSMENT

ALWAYS SOMETIMES RARELY NEVER

Reads and understands
written word (single word)

Reads and understands

written word (simple
sentences)

Reads and understands

extended written phrases
(paragraphs, books, etc.)

Initiates interactions using

written word

Uses written word to indicate

wants and needs

Uses written word to indicate

personal choice

Uses written word to indicate

medical concerns

Uses written word to indicate

emotional states

Uses written word to indicate

personal or emergency
information

Uses written word to write

descriptively or tell a story

Follows 1 step written

directions

Follows multi- step written

directions

Picture (visual) Communication

ALWAYS SOMETIMES RARELY NEVER

Understands what a picture stands
for or represents

Focuses on pictures when presented

Initiates interactions with picture

communication (PECs cards, etc.)

Uses pictures to indicate wants and

needs

Uses pictures to indicate personal

choice

Uses pictures to indicate medical

concerns

Uses pictures to communicate

emotional states

Uses pictures to communicate

personal and emergency information

Uses pictures or visual cues to

describe events or tell a story

Follows 1 step picture directions

Follows multi-step picture systems

Follows picture schedule

 Electronic Communication assessment

ALWAYS SOMETIMES RARELY NEVER

Uses ECD to initiate interactions
with others

Understands what pictures on

the ECD represent

Able to navigate device menu

independently

Able to construct sentences

using ECD

Uses ECD to indicate wants and

needs

Uses ECD to indicate personal

choice

Uses ECD to communicate

emotional states

Uses ECD to communicate

medical concerns

Uses ECD to communicate

personal or emergency
information

Uses ECD to describe events or

tell a story

PLEASE COMPLETE EACH QUESTION ON THE CLIENT

1. I N GENERAL , HOW DOES CLIENT COMMUNICATE WITH PEERS?

2. I N GENERAL , HOW DOES CLIENT COMMUNICATE WITH STAFF ?

3. HOW DOES CLIENT COMMUNICATE WITH FAMILY?

4. HOW DOES CLIENT COMMUNICATE IN COMMUNITY?

5. HOW DOES CLIENT COMMUNICATE WHEN INTRODUCED TO NEW PERSON ? DOES CLIENT HAVE
ISSUES THAT EFFECTS COMMUNICATION ? ( SPEECH IMPAIRMENT , EMOTIONAL , ANXIETY,
ENVIRONMENTAL STRESSORS, MEDICAL CONDITION ) P LEASE BE DESCRIPTIVE.

6. HOW DOES THE CLIENT COMMUNICATE WHEN EXPERIENCING A MEDICAL ISSUE OR EMERGENCY ,
OR WHEN EXPERIENCING PAIN?

7. HOW DOES THE CLIENT COMMUNICATE THEIR EMOTIONAL STATE TO FRIENDS , STAFF AND PEERS?

8. WHAT IS THE MOST EFFECTIVE WAY TO COMMUNICATE WITH THIS INDIVIDUAL ?