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Aphasia Mentors Program

AMP - Program Overview

AMP - Group Work Philosophy

AMP - Get Involved

AMP - Referral Form

AMP – Referral Form

Aphasia Mentors Program Referral From

Referring Agent Information:
Date of Referral
Referred by
- SLP
- *Family
- *Self
- *Other
Contact Details of Referring Agent
Client Information:
Name of Client
Phone
Email
Preferred Contact Person (if not client)
Date of Birth
Date of Incident
Type of Incident
- Stroke
- TBI
- PPA
- Other
Number of Incidents
(Pre-incident) occupation
Languages Spoken
Marital Status
Family/Friends/Pets
Hobbies
Hometown (i.e. growing up)
Current Address
At which campus would you attend in-person sessions?
- Vancouver (Point Grey Campus)
- Victoria (VITP Campus)
Prior SLP Therapy incl. community groups
Other physical impairments (e.g., hemiplegia, loss of balance)
Emergency Contact Info
Name
Relationship to Client
Phone
Email

Aphasia Type
Based On
- Informal assessment/Observation
- Formal Assessment
Expressive Abilities
Expression
Oral Expression - Client Communicates using:
- non-word syllables
- words
- phrases
- sentences
- multiple sentences
- numbers
Written Expression - Client Communicates using:
- letters
- numbers
- words
- phrases
- sentences
- paragraphs
Written Expression - Format
- Written
- Text
- Keyboard
AAC/Technology - Client Communicates using:
- Smart Phone
- Tablet
- Computer (Laptop/PC)
- AAC Device
Gesture - Client communicates using gesture that is:
- relevant to the message being conveyed
- unclear whether related to the message being conveyed
Receptive Abilities
Comprehension
Receptive Abilities
Client Comprehends
- Simple Information - With Support
- Simple Information - Without Support
- Complex Information - With Support
- Complex Information - Without Support
Client's comprehension of speech:
Rate on a scale of 1-10, with
1 = really hard and
10 = really easy
in one on one settings
in quiet environments
in small groups (2 to 3 people)
in larger groups (4 to 5 people)
in noisy environments (eg., a restaurant)
Client's reading comprehension
- words
- phrases
- paragraphs
- pages of text
- numbers

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School of Audiology & Speech Sciences

Faculty of Medicine

2177 Wesbrook Mall

Vancouver, BC Canada V6T 1Z3

Tel 604 822 5591

Fax 604 822 6569

Email inquiry@audiospeech.ubc.ca

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