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Compass Referral
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We may share details of this referral with Environment Control services, Wheelchair services and with local health and social care professionals where it helps to ensure a fully integrated service is provided in response to the referral. If you do not want us to do this, please let us know by emailing
Compass
Patient
NHS Number
Title
Mr
Mrs
Miss
Ms
Dr
Professor
Sir
Reverend
First Name
Middle Names
Last Name
Date of Birth
Email Address
Telephone
Alternate Phone
Gender
Male
Female
Other
Prefer Not To Say
Ethnic Origin
White British
White Irish
Any other White background
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Asian
Mixed - Any other mixed background
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British Bangladeshi
Any other Asian background
Black or Black British Caribbean
Black or Black British African
Any other Black background
Chinese
Any other ethnic group
Refuses to Disclose
Address
Post Code
Name / Company
Line 1
Line 2
Line 3
Town
County
Country
Address Type
Private House
Supported Living
Care Home
Rehabilitation Unit
Acute Hospital Ward
GP
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GP
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You can search by the surname of the GP, the name of the Practice and the address of the Practice
Referrer
Title
Mr
Mrs
Miss
Ms
Dr
Professor
Sir
Reverend
First Name
Last Name
Email Address
Telephone
Alternate Phone
Address
Post Code
Name / Company
Line 1
Line 2
Line 3
Town
County
Country
Other Details
Profession
Advanced Practitioner - Assistive Technology
Carer / Relative
Clinicial Lead For Assistive Technology
Consultant
Clinical Scientist
Clinical Technologist
General Practitioner
Nursing Home Staff
Other Allied Health
Orthotist
Occupational Therapist
Physiotherapist
Physiotherapy Assistant
Rehabilitation Engineer
Rehab Technician
Self
Speech & Language Therapist
Support Worker
Social Worker
Technology Support Worker
Special Contact Instructions
Referral Detail - Part 1
Primary Diagnosis
Neurological - Ataxia
Neurological - Traumatic Brain Injury
Neurological - Cva (left)
Neurological - Cva (right)
Neurological - Cva (unspecified)
Neurological - Cerebral Palsy Cp
Neurological – Down Syndrome
Neurological - Diplegia
Neurological - Epilepsy
Neurological - Hydrocephalus
Neurological - ME
Neurological - Motor Neurone Disease MND
Neurological - Multiple Sclerosis MS
Neurological - Myelitis
Neurological - Paraplegia
Neurological - Parkinsons
Neurological - Poliomyelitis
Neurological - Quad/tetraplegia
Neurological - Spastic Paraparesis
Neurological - Spina Bifida
Neurological - Subdural Haematoma
Neurological - Other Neurological
Neurological - Other Degenerative Neuro
Neurological - Autistic Spectrum Disorder Asd
Neurological - Hypoxic Brain Injury
Neurological - Multi-System Atrophy Msa
Neurological - PSP
Neurological - Dysarthria
Neurological - Aphasia / Dysphasia
Neurological - Hemiparesis (left)
Neurological - Hemiparesis (right)
Neurological - Subarachnoid Haemorrhage
Neurological - Rett Syndrome
Non-Specific - Acquired Immune Def
Non-Specific - Alzheimers Disease
Non-Specific - Cancer
Non-Specific - Dementia
Non-Specific - Developmental Delay
Non-Specific - Diabetes
Non-Specific - Learning Disabilit Ld
Non-Specific - Reduced Mob/frailty
Non-Specific - Visual Impairment
Non-Specific - Other Non-Specific
Non-Specific - Prader-Willi Syndrome
Orthopaedic - Arthritis (unspec)
Respiratory - Asthma
Respiratory - C.O.A.D
Respiratory - Cystic Fibrosis
Respiratory - Emphysema
Respiratory - Other Respiratory
Respiratory - Chronic Obstructive Pulmonary Disease (COPD)
Secondary Diagnosis 1
Neurological - Ataxia
Neurological - Traumatic Brain Injury
Neurological - Cva (left)
Neurological - Cva (right)
Neurological - Cva (unspecified)
Neurological - Cerebral Palsy Cp
Neurological – Down Syndrome
Neurological - Diplegia
Neurological - Epilepsy
Neurological - Hydrocephalus
Neurological - ME
Neurological - Motor Neurone Disease MND
Neurological - Multiple Sclerosis MS
Neurological - Myelitis
Neurological - Paraplegia
Neurological - Parkinsons
Neurological - Poliomyelitis
Neurological - Quad/tetraplegia
Neurological - Spastic Paraparesis
Neurological - Spina Bifida
Neurological - Subdural Haematoma
Neurological - Other Neurological
Neurological - Other Degenerative Neuro
Neurological - Autistic Spectrum Disorder Asd
Neurological - Hypoxic Brain Injury
Neurological - Multi-System Atrophy Msa
Neurological - PSP
Neurological - Dysarthria
Neurological - Aphasia / Dysphasia
Neurological - Hemiparesis (left)
Neurological - Hemiparesis (right)
Neurological - Subarachnoid Haemorrhage
Neurological - Rett Syndrome
Non-Specific - Acquired Immune Def
Non-Specific - Alzheimers Disease
Non-Specific - Cancer
Non-Specific - Dementia
Non-Specific - Developmental Delay
Non-Specific - Diabetes
Non-Specific - Learning Disabilit Ld
Non-Specific - Reduced Mob/frailty
Non-Specific - Visual Impairment
Non-Specific - Other Non-Specific
Non-Specific - Prader-Willi Syndrome
Orthopaedic - Arthritis (unspec)
Respiratory - Asthma
Respiratory - C.O.A.D
Respiratory - Cystic Fibrosis
Respiratory - Emphysema
Respiratory - Other Respiratory
Respiratory - Chronic Obstructive Pulmonary Disease (COPD)
Secondary Diagnosis 2
Neurological - Ataxia
Neurological - Traumatic Brain Injury
Neurological - Cva (left)
Neurological - Cva (right)
Neurological - Cva (unspecified)
Neurological - Cerebral Palsy Cp
Neurological – Down Syndrome
Neurological - Diplegia
Neurological - Epilepsy
Neurological - Hydrocephalus
Neurological - ME
Neurological - Motor Neurone Disease MND
Neurological - Multiple Sclerosis MS
Neurological - Myelitis
Neurological - Paraplegia
Neurological - Parkinsons
Neurological - Poliomyelitis
Neurological - Quad/tetraplegia
Neurological - Spastic Paraparesis
Neurological - Spina Bifida
Neurological - Subdural Haematoma
Neurological - Other Neurological
Neurological - Other Degenerative Neuro
Neurological - Autistic Spectrum Disorder Asd
Neurological - Hypoxic Brain Injury
Neurological - Multi-System Atrophy Msa
Neurological - PSP
Neurological - Dysarthria
Neurological - Aphasia / Dysphasia
Neurological - Hemiparesis (left)
Neurological - Hemiparesis (right)
Neurological - Subarachnoid Haemorrhage
Neurological - Rett Syndrome
Non-Specific - Acquired Immune Def
Non-Specific - Alzheimers Disease
Non-Specific - Cancer
Non-Specific - Dementia
Non-Specific - Developmental Delay
Non-Specific - Diabetes
Non-Specific - Learning Disabilit Ld
Non-Specific - Reduced Mob/frailty
Non-Specific - Visual Impairment
Non-Specific - Other Non-Specific
Non-Specific - Prader-Willi Syndrome
Orthopaedic - Arthritis (unspec)
Respiratory - Asthma
Respiratory - C.O.A.D
Respiratory - Cystic Fibrosis
Respiratory - Emphysema
Respiratory - Other Respiratory
Respiratory - Chronic Obstructive Pulmonary Disease (COPD)
Other Diagnosis
Date of Onset
Please complete the detail in the below text box by expanding on the headings that are already entered for you. Use the expandable boxes below to help you, you can copy and paste the headings into the text box if it helps to structure your comments
Current Communication
Strengths and Weaknesses
Please describe the patients strengths and weaknesses in terms of communication, for example in relation too:
Speech
Voice
Language - Expressive
Language - Receptive
Writing
Reading
Current Methods
Please describe in what ways the patient currently communicates. If the patient uses a method please describe any relevant limitations and issues encountered. Examples types of communication are given below:
Verbal
Written
Partner Assisted Scanning
Low tech AAC (e.g. paper chart or E-Tran Frame)
Gesture / Signing / Facial Expression
High tech AAC Device
Reliability
Please describe how reliably the patient can communicate and any verbal or physhical assistance they require in doing so.
Communication Needs
Reason for Referral
Please detail a referral is being made to the Compass team at RHN
Key Communication Partners
Please detail who the patient needs to communicate with
Patient / Relative / Carer Goals
Please detail any goals for using a communication aid. Specifically, how would high-tech AAC be of benefit beyond a low-tech AAC solution?
Patient Interests and Preferences
What interests or hobbies are motivating for this Patient? Are there any known dislikes or triggers that we should be aware of?
Equipment already assessed
Please detail any Communication Equipment or techniques already assessed and what the outcomes were
Current Communication Communication Needs Equipment already assessed / trialled
Referral Detail - Part 2
Please complete the detail in the below text box by expanding on the headings that are already entered for you. Use the expandable boxes below to help you, you can copy and paste the headings into the text box if it helps to structure your comments
Motor / Sensory / Cognitive Detail
Please detail weakness with reference to the below categories. Please specify if LEFT or RIGHT or BOTH where relevent:
Upper Limbs - Decreased range, Decreased strength, Contractures, Dyspraxia, Ataxia, Increased tone, Poor Coordination
Head/Neck Control - Rotation, Flexion, Extension
Eye Movement - Vertical Movement, Horizontal Movement, Nystagmus, Strabismus
Sensory / Perceptual - Registered Blind, Visual Impairment, Unilateral Neglect, Hearing Impairment
Cognitive - Memory Impairment, Reduced learning ability, Reduced attention span, Reduced reasoning/problem solving
Mobility - Ambulant, Manual Wheelchair, Powered Wheelchair, Adaptions eg Headrest/tray
Behaviour - Challenging Behaviour, Risk of developing challenging behaviour due to not being able to communicate
Potential ways to control AAC - Keyboard, touchscreen, switches, joysticks / trackball, Headmouse / pointer, Eyegaze, Other
Mobility Detail
Please detail the mobility needs of your client.
Ambulant - Assistance or aids
Manual Wheelchair - Model
Powered Wheelchair - Model
Powered Wheelchair - Controller
Adaptations - Uses Headrest or Wheelchair tray
Practical / Other Detail
Practical Issues Regarding Assessment
Please comment on any difficulty regarding the below:
Travel to assessment
Parking Availability at property
Internet Access
Access to Skype or other facetime for assessment
Other Comments
Please make any other comments you wish to in this section
Motor, Sensory, Cognitive Details Mobility Details Practical and Other Issues
