Sequal Assessment Form

When completing this form, please bear in mind that we are unable to meet the member in person and therefore require FULL COMPLETION OF ALL SECTIONS. ** Failure to do so could result in applications being returned. Thank you for your time.

THIS FORM MUST BE FULLY COMPLETED AND SOLELY BY THE PROFESSIONAL ASSESSING BODY – EITHER A SPEECH AND LANGUAGE THERAPIST OR A SPECIAL NEEDS TUTOR.

Assessor’s Information:

Assessor's Date:(Required)

Assessor's Name:(Required)

Assessor’s Contact Number:(Required)

Assessor’s Professional Capacity:(Required)

Assessor’s Relationship To Member, If Any:(Required)

Assessor’s Contact Address:(Required)

Assessor’s Email:(Required)

PLEASE NOTE:

We would be grateful if you could approach the NHS hubs and other avenues of statutory funding before applying to Sequal, as our funds are limited. Please complete box below with their responses, together with details of applications made to any other organisation for funding, so that we are aware of any monies that may be forthcoming.

NHS Response

Member’s (Applicant’s) Personal Details:

Member’s Name:(Required)

Member’s DOB:(Required)

Home Address:(Required)

Telephone Number:(Required)

British Citizen(Required)

I confirm that this person is a British Citizen and I have seen evidence where applicable

I confirm that this person was born outside the UK and will provide documentation for this

Other contact details e.g. school or day centre or Residential Home(Required)

Does the member have a communication aid at the moment? If so, please provide details(Required)

Disability Details:

Member’s disability(Required)

How does this affect the member’s communication and/or movement?(Required)

Is this disability likely to improve or deteriorate in the future?(Required)

What are the effects of the disability and how will the recommended equipment improve those e.g. long term medication, confidence, independence or education.(Required)

Please complete all boxes. A = Very Good B = Good C = Fair D = Poor E = Nil

Left Arm(Required)

Right Arm(Required)

Eyesight(Required)

Recall(Required)

Left Hand(Required)

Right Hand(Required)

Speech(Required)

Humour(Required)

Left Fingers(Required)

Right Fingers(Required)

Head / Neck(Required)

Motivation(Required)

Left Foot(Required)

Right Foot(Required)

Breathing(Required)

Wheelchair Y/N(Required)

Left Leg(Required)

Right Leg(Required)

Memory(Required)

Bedbound Y/N(Required)

Equipment Required

**PLEASE NOTE THAT EQUIPMENT TRIALS NEED TO BE ARRANGED TO ENSURE SUITABILITY BEFORE WE ARE ABLE TO ACCEPT A RECOMMENDATION. PLEASE ADVISE US IF ASSISTANCE IS REQUIRED IN THIS AREA.

Untitled(Required)

Tower/laptop/iPad

AAC Type and Model : e.g Lightwriter SL40 Connect, Tobii I-12 etc

(Please note that an iPad can only be provided if communicational app required)

Device:(Required)

Software/app recommended:(Required)

Full details of any accessories/ access devices required : e.g. track or roller ball, touch screen, case etc Is training required?(Required)

Software required:(Required)

I confirm that detailed trials have taken place for…………….weeks(Required)

Details of supplier conducting trials(Required)

Make & Model of wheelchair and exact mount needed.(Required)

Where system to be delivered to when fund raising complete.(Required)