Kids Chat - Application Form
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1 Kids Chat - Application Form Non-electronic Communication Aid Scheme (NECAS) for children Kids Chat makes customised communication aids. This means that all content and design instructions need to be included in the application. We do not provide generic communication aids. It is important to know exactly what aid you are applying for. Talk to the child s family, education and therapy team before sending in this application form. Instructions ALL information must be provided before requests can be processed. If you are completing this form for the person, you must know the person and their communication needs well, eg. a speech pathologist, support worker, friend or family member. If you need more information about how to design a communication aid please see How to design a communication aid - Handout on What is funded? Individualised communication aids funded under Kids Chat: Communication aids which help a person to get their message across e.g. communication books, activity schedules and picture symbols Communication aids used in specific settings e.g. community request cards Visual communication supports which help a person to understand e.g. timetables, social stories Supports designed for communication partners to get information e.g. book about me Who can get a funded non-electronic communication aid? Children who: are 17 years old or younger live in Victoria have speech difficulties are eligible for services under the Disability Act (2006) Who can not apply for a funded non-electronic communication aid? Children who: have clear speech get support from the Transport Accident Commission (TAC) have a plan through NDIS Please note: If you need a communication aid translated into another language, please write this on the form If you would like some advice on how to design a communication aid or if you think your application should be considered a priority, please contact us Kids Chat is a pilot project to provide a limited amount of communication aids. Please refer to the Kids Chat guidelines for more information. Please return this form to: Scope s Communication & Inclusion Resource Centre 830 Whitehorse Road, Box Hill, VIC 3128 Fax: (03) circ@scopevic.org.au Phone: (03)
2 Date of application:... /... /... Child s Details Name:... Address:... Suburb:... Postcode:... Telephone:... Date of birth:... /... /... Gender: [] Male [] Female Primary diagnosis: [] Autism Spectrum Disorder [] Cerebral Palsy [] Stroke [] Down Syndrome [] Intellectual Disability [] Degenerative Neurological Condition [] Other:... Who will support the use of this communication aid? [] Family [] Friends [] School / Teacher [] Speech Pathologist [] Therapists [] Support worker [] Other... Does the child currently have access to a speech pathologist? [] Yes [] No If yes, who?... Does the child: - walk? [] Yes [] No - have a vision impairment? [] Yes [] No - have spelling skills? [] Yes [] No - have clear speech? [] Yes [] No 2
3 Your Request What communication aid is being requested? Write one aid only. Communication aid requested :... Please see our website page for examples of the types of aids we frequently make. You will need to give us all of the information to make the aid on pages 4-6. Does the child currently have a communication aid? [] Yes [] No Please note: this information is for our data collection purposes only. The answer to this question will not affect the outcome of your application. If yes, is this a request for: [] A replacement or update of an existing communication aid (please provide an electronic copy or photocopy if available). [] An additional back-up system to an existing communication aid, e.g. to use in other environments or when the existing aid cannot be used. How will this communication aid assist the child? [] Give him/her a tool to communicate their needs and wants [] Help him/her understand what is happening [] Reduce their frustration [] Increase independence [] Allow or increase participation in activities [] Develop relationships with people [] Give others information about how to communicate/interact with the applicant How will the communication aid be used by the child? [] Point with finger [] Whole hand or fist [] Head pointer [] Eye gaze [] Partner assisted scanning [] Other:... 3
4 Designing the aid Think about portability of the aid size of text size of images complexity of the page Title of the aid... Size of the aid [] A5 (15 x 21 cm) [] A4 (21 x 30 cm) [] A3 (29.7 x 42 cm) [] Cards - specify size:... [] Other - specifiy size:... Orientation Portrait Landscape Font size Font is set at Arial or Century Gothic [] 12pt [] 14pt [] 16pt [] Other:... Content [] Words only [] Alphabet (QWERTY or ABC layout) [] Numbers (1-10, 100, 1000 etc.) [] Images/symbols [] COMPIC [] Picture Communication Symbols (Boardmaker) [] Symbolstix [] Personal photos* [] Internet photos [] Object symbols** [] Other:... Note: * Please send personal photos in an electronic format via or on USB. Please label the photos. ** Please identify what object you would like to include, based on what is most appropriate for the child. 4
5 Design features (if applicable) Tabs: [] Yes [] No Favourite colours for customisation: Instructions on how to use the communication aid (for communication partners)... Contact details to be printed on the communication aid Name:... Address: Phone:... For communication books only Number of items on a page (symbols per page): [] 2 [] 4 [] 8 [] 12 [] Other:... Finish on the aid (select all that apply) [] Laminated [] Magnetic [] Coil binding [] Hook and Loop [] Keyring/lanyard [] Binder folder [] Folder with pockets [] Hook and Loop compatible board [] Retractable card holder [] Diary/personal organisers [] Whiteboard Additional details Please give us the vocabulary or list of words you want included in the aid, on the next page You can do a drawing of the pages if that helps you explain what you want Please attach more pages if needed 5
6 Content of the aid In order to process this application, we need all of the words and layout information for the aid. We can match pictures/photos to the words provided, where you aren t able to supply these. Without this information, your application will NOT be processed. 6
7 Applicant information (the person filling in this form) *This person may be contacted for further information Name:... How do you know the child?:... Organisation (if applicable):... Address of organisation:... Postcode:... Telephone number: We will provide a draft electronically (PDF) via . How did you find out about Kids Chat? [] Scope website [] Through somebody who has used it before [] At a presentation [] Through written material from Scope [] Other:... Final product Who is the final communication aid to be sent to? [] Applicant (person filling in form) [] Child (as per address on page 2) Additional Information:... Consent Information from your application will be collected and may be used for evaluation, quality assurance activities, research and education. These activities help us improve our services. Information will be de-identified of names and organisation details. It will be treated as private and confidential. Scope only collects information that is directly relevant to effective service delivery. Information may appear in reports or other publications. Scope is conducting research about the Kids Chat service. Scope may contact you to invite you to participate in the research. If you do not want the information to be used in this way, or if you do not wish to be contacted about being involved in research, please circ@scopevic.org.au. Your decision to opt out will not affect the services you receive from Scope. [] I give my consent for the aid to be used as a communication aid example [] I authorise Kids Chat to produce the communication aid as outlined in this form Parent/Guardian Signature: Date: Printed Name:
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