CBS Request Form for Development of Communication Support
CBS Request Form for Development of Communication Support
CBS Request Form for Development of Communication Support
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<strong>Communication</strong> Board Service<strong>Request</strong> <strong>for</strong> <strong>Communication</strong> <strong>Support</strong>sTherapist: _________________________________________________________________________________Organisation: ______________________________________ Phone: _______________________________Client: ____________________________________________ DOB:_____________________ M FMake account to: (Please complete in<strong>for</strong>mation below)□ CAEATI - <strong>Communication</strong> <strong>Support</strong>- Community Aids, Equipment and Assistive Technology Initiatives□ Better Start Initiative(Better Start Registered clients only)□ Client-self funded□ Fee-<strong>for</strong>-service□ OtherInvoices <strong>for</strong> this service should be addressed to:Contact Name:Company:Address:Telephone:Fax:ABN:Email:Reference number:(if required)Signed:(must be person authorised to incur expense)Name:Role:Date:<strong>Communication</strong> <strong>Support</strong> Item/s – please select:PODD Direct Access Templates: 9 per page early functions 9 per page expanded functions 12 per page early functions 12 per page expanded functions 16 per page expanded functions 20 per page expanded functions Group book – early functions Group book – expanded functions 40 key word 70 expanded key word 100 plus complex syntax 36 key word 48 expanded key word 90 plus complex syntax01.11.05.14.01 April 2013 Page 1 <strong>of</strong> 4Approved by: Mgr PST - Uncontrolled when printed - Review Date: 10/2012
<strong>Communication</strong> Board Service<strong>Request</strong> <strong>for</strong> <strong>Communication</strong> <strong>Support</strong>sCustomised communication book (different to PODD):Therapist to supply vocabulary/content sheetsAided Language Stimulation (ALS) – topic specific display/s:Quantity:(number <strong>of</strong> boards)Other, please specify:<strong>Communication</strong> support items and design requirementsPlease tick appropriate and then specify details on your draft.Cover design is to include: First name <strong>of</strong> client Surname <strong>of</strong> client Font _________________________ Photograph (please provide) Colour__________________________________________ Graphics ______________________________________________ (Emailed JPEG files are acceptable)(Give as much in<strong>for</strong>mation as you can here, even if it’s not specific i.e. colour: blue or green; Brisbane Lionscolours; font: large & clear; Ravie style; graphics: loves sports; Broncos; fairies, etc.)Finish <strong>for</strong> covers:Laminate: Hard – Gloss 250µ S<strong>of</strong>t – Gloss 80µ S<strong>of</strong>t – Matt 80µDesign: Board Book No. <strong>of</strong> Pages: _____ Single Sided Double SidedSize <strong>of</strong> Page: Height (cm) _______ Width (cm) ______Type <strong>of</strong> Grid: Continuous Spaced Other (provide details on your draft)Line Weight: Thin Medium ThickSize <strong>of</strong> Cell: Height (cm) _______ Width (cm) ______Number <strong>of</strong>: Rows ____________ Columns ________Colour: Coloured Background Coloured Cell Coloured Cell Line Coloured Grid Lines Coloured Paper OtherSymbols:Type: PCS COMPIC ’Picture This’ Photos Clipart Text Only Signing Client PhotosSize: Small Medium Large Best FitColour: Colour Black & White Negative Image (Specify eg. yellow on navy)01.11.05.14.01 April 2013 Page 2 <strong>of</strong> 4Approved by: Mgr PST - Uncontrolled when printed - Review Date: 10/2012
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