Assistive Technology Referral
Full Name:
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First Name
Last Name
Birth Date:
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Year
Age:
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District
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Please Select
Ashland Ind. Schools
Augusta Ind. Schools
Bath County Schools
Boyd County Schools
Carter County Schools
Elliott County Schools
Fairview Ind. Schools
Fleming County Schools
Greenup County Schools
Johnson County Schools
Lawrence County Schools
Lewis County Schools
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Mason County Schools
Menifee County Schools
Morgan County Schools
Paintsville Ind. Schools
Raceland Ind. Schools
Robertson County Schools
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Other (Please describe with School)
School:
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Grade:
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Please Select
PreSchool
Kindergarten
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School Contact:
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First Name
Last Name
Contact Phone Number:
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Area Code
Phone Number
Contact E-mail:
*
Parent:
*
First Name
Last Name
Parent Phone Number:
-
Area Code
Phone Number
Parent E-mail:
Disability:
(If Multiple, Check all that apply)
Disability:
Speech/Language
Developmental Delay
Specific Learning Disability
Mild Mental Disability
Functional Mental Disability
Emotional/Behavioral Disability
Hearing Impairment
Traumatic Brain Injury
Autism (Spectrum)
Vision Impairment
Other Health Impairment
Orthopedic Impairment
OHI Description:
OI Description:
How is this disability manifested in regards to the student’s education?
Describe how this disability keeps the student from being able to perform on par with peers
Educational relevance of disability
What part(s) of the standard curriculum does the student have difficulty with due to the disability?
Classroom Setting:
Regular Education Classroom
Resource Room
Self-Contained
Home
Other
Amount of time (per day) spent receiving Special Ed Services:
Rationale:
Please explain why the student is receiving instruction in the setting chosen
Current Service Providers:
Occupational Therapy
Physical Therapy
Speech/Language Therapy
Other
Medical Consideration
(Check all that apply):
Medical:
History of Seizures
Degenerative Medical Condition
Multiple Health Problems
Frequent Ear Infections
Fatigues Easily
Frequent Pain
Frequent Upper Respiratory Infections
Digestive Problems
Allergies
Current Medications
Other
Allergies:
Current Medications:
Other:
Other Issues of Concern:
Assistive Technology Currently Used:
(Or tried in the past):
AT Used:
None
Low Tech Writing Aids
Manual Communication Board
Augmentative Communication Device (GoTalk, Dynavox, etc.)
Low Tech Vision Aids
Amplification System
Environmental Control Unit (EADL)
Manual Wheelchair
Power Wheelchair
Ambulatory Device
Computer
Word Prediction
Voice Recognition
Adaptive Input
Adaptive Output
iPad/Tablet
Other
Low Tech Writing Aids
Manual Communication Board
Augmentative Communication Device (Device used):
Low Tech Vision Aids
Amplification System (Type of system and how utilized)
Environmental Control Unit (EADL)
Manual Wheelchair (Customizations or accommodations)
Power Wheelchair
Ambulatory Device (Walker, gait trainer, etc.)
Computer (Type and uses)
Word Prediction
Voice Recognition
Adaptive Input (alternate mouse, keyboard, etc.)
Adaptive Output (refreshable braille, etc.)
iPad/Tablet (Type and specific apps utilized)
Other (describe):
Assistive Technology Device Outcomes:
Please describe if the device(s) were effective and why or why not)
Referral Question
What task(s) does the student need to do that is currently difficult or impossible, and why is assistive technology an option?
Based on the referral question, what areas of functioning appear to be the most affected?
(Check all that apply.)
Fine Motor (Related to Computer or Device Access)
Motor Aspects of Writing
Composing Written Material
Communication
Reading
Learning and Studying
Math
Recreation and Leisure
Seating and Positioning
Mobility
Vision
Hearing
General
What type of AT Consultation would be most appropriate for this student?
*
Comprehensive AT Consultation/Assessment (Requires extensive information gathering from school stakeholders, and interviews, observations, and/or assessments from an AT provider. The completed report is more extensive and provides a more reliable form of documentation for due process folders.)
Individualized AT Consultation (Requires some information gathering from school stakeholders, and interviews/observations from an AT provider. The completed report will only include AT recommendations.)
General AT Consultation (Requires minimal information gathering from school stakeholders. Focus is on the classroom or teacher support. Consultation can be face to face or via electronic media. A report may/may not be necessary.)
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