Deaf Services Screening Profile Name: DMH ID: Regional Office: TCM Provider: Person Completing Form: This individual uses American Sign Language (ASL): No Yes* *If yes, stop completing this form and use procedure described in Expressive Language Preferred Language be in or for most ability can usable used some use or in situations no ability be routine Has situations Can minimal used Has incidental Can communication some Fluent Spoken English Other Spoken Language Fingerspelling Gesture/Pantomime Written English Drawing/Pictures Other Information: Receptive Language Preferred Language in or most can for ability usable used or in some use situations no ability be routine Has used situations Can minimal Fluent Has incidental Can communication some be Spoken English Lipreading Other Spoken Language
Deaf Services Screening Profile Name: DMH ID: Regional Office: TCM Provider: Person Completing Form: This individual uses American Sign Language (ASL): No Yes* *If yes, stop completing this form and use procedure described in Expressive Language Preferred Language Has no usable ability Has some minimal ability Can use for incidental or routine communication Can be used in some situations Fluent or can be used in most situations Spoken English Other Spoken Language Fingerspelling Gesture/Pantomime Written English Drawing/Pictures Other Information: Receptive Language Preferred Language Has no usable ability Has some minimal ability Can use for incidental or routine communication Can be used in some situations Fluent or can be used in most situations Spoken English Lipreading Other Spoken Language