Consult Request Form

Assistive Technology Consult Request Form
Date Submitted:

MonthDayYear
Consult Requested by:
School District/Organization:
Student Information:
Student Name:

First NameLast Name
Date of Birth:

MonthDayYear
Age:
Disability(s):
Current Grade:
Daily Schedule:
(including arrival/departure, related service times, etc.)
School Year Start Date:
School Year End Date:
Unavailable Dates for Scheduling:
(i.e. field trip, program, etc.)
Current Educational Placement:
(classroom, related services, grade placement, etc.)
Brief description of student's abilities:
Assistive Technology in Place or Tried with Student:
Describe any assistive technology currently being used.
Describe any assistive technology previously tried.
Please include AT name, length of trial, and result.
Primary Area(s) of Concern Related to AT:
1-Please check the primary area(s) of concern for the student related to assistive technology.
1-List the specific task(s) you want the student to do that s/he is unable to do, at a level that reflects his/her skills & abilities.
1-Additional areas of concern?
2-Please check the primary area(s) of concern for the student related to assistive technology.
2-List the specific task(s) you want the student to do that s/he is unable to do, at a level that reflects his/her skills & abilities.
2-Additional areas of concern?
3-Please check the primary area(s) of concern for the student related to assistive technology.
3-List the specific task(s) you want the student to do that s/he is unable to do, at a level that reflects his/her skills & abilities.
3-Additional areas of concern?
4-Please check the primary area(s) of concern for the student related to assistive technology.
4-List the specific task(s) you want the student to do that s/he is unable to do, at a level that reflects his/her skills & abilities.
4-Additional areas of concern?
5-Please check the primary area(s) of concern for the student related to assistive technology.
5-List the specific task(s) you want the student to do that s/he is unable to do, at a level that reflects his/her skills & abilities.
5-Additional areas of concern?
Parent Information:
Parent Name (1):

First NameLast Name
Parent Name (2):

First NameLast Name
Phone Number (preferred):

Area CodePhone Number
Phone Number (preferred) Type
Phone Number (alternate):

Area CodePhone Number
Phone Number (alternate) Type
E-mail (Parent 1):
E-mail (Parent 2):
School District Information:
School District Name:
School Campus Name:
Campus Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Contact Information:
Primary Contact Name:

First NameLast Name
Phone (preferred):

Area CodePhone Number
Phone (alternate):

Area CodePhone Number
Preferred Time(s) to be Contacted:
Primary Contact's E-Mail:
Primary Contact's Relationship/Role to Student:
Does your district have an Assistive Technology Team?
If Yes, please provide name and contact information.
Special Education Director Information:
Special Education Director's Name:

First NameLast Name
Phone Number:

Area CodePhone Number
E-mail:
Hourly Fees + Travel (An estimate of hours will be provided after reviewing request)
Should be Empty:

Assistive Technology Consult Request Form

Student Information:

Assistive Technology in Place or Tried with Student:

Primary Area(s) of Concern Related to AT:

Parent Information:

School District Information:

Primary Contact Information:

Special Education Director Information: