Quality of Communication Life Scale Score: _____________ Step IV: Current Communication Needs Environments: Check all the client participates in Home/Residence Telephone School Community Work Support Group Medical Facility Other: Face-to-Face Other: Partners: Check all partners with whom client interacts Immediate Family Medical professionals Extended Family Home health assistants/caregiver Friends Individuals in community Peers Other: Teachers Other: Residential Staff Other: Topics: Check all topics about which the client needs to communicate Activities of Daily Living (ADLs) Medical Needs Medical/Personal/Legal Decision-making Emergency needs/information Personal needs Personal information Other: Functions: Ask questions Respond to questions Social interaction (family and community) Social etiquette Resolve/prevent communication breakdowns Other: Summary and Prognosis: Choose one of the following
Quality of Communication Life Scale Score: _____________ Step IV: Current Communication Needs Environments: Check all the client participates in Home/Residence Telephone School Community Work Support Group Medical Facility Other: Face-to-Face Other: Partners: Check all partners with whom client interacts Immediate Family Medical professionals Extended Family Home health assistants/caregiver Friends Individuals in community Peers Other: Teachers Other: Residential Staff Other: Topics: Check all topics about which the client needs to communicate Activities of Daily Living (ADLs) Medical Needs Medical/Personal/Legal Decision-making Emergency needs/information Personal needs Personal information Other: Functions: Ask questions Respond to questions Social interaction (family and community) Social etiquette Resolve/prevent communication breakdowns Other: Summary and Prognosis: Choose one of the following