Assistive Technology Evaluation Request
AT Solutions LLC
School District
*
Name of person completing form
First Name
Last Name
Title
Student Information
Student Name
*
First Name
Last Name
Grade
*
Current School
*
Student Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Female
Male
Other
IEP Educational Classification
Specific Learning Disability (SLD)
Other Health Impairment (OHI)
Emotional Disturbance (ED)
Autism spectrum disorder (ASD)
Hearing Impairment
Intellectual Disability
Multiple Disabilities
Orthopedic Impairment
Speech or Language Impairment
Traumatic brain injury (TBI)
Visual Impairment, including blindness
Deaf-blindness
Medical Diagnoses
Parent/ Guardian Name
First Name
Last Name
Relationship to Student
Parent/ Guardian Phone Number
Parent/ Guardian Email
Reason for Referral
What would you like to see the student do, that he or she cannot do now?
Key School Staff
Case Manager Name
First Name
Last Name
Case Manager Email
Case Manager Phone
Teachers *Indicate Special Education or General Education*
Related Services Staff (Para, OT, SLP)
School Technology Representative
First Name
Last Name
School Technology Rep. Email
example@example.com
Communication Preferences
Rows
Contact for Background Information
Contact for Scheduling
Send Report to
Parent
Case Manager
General Education Teacher
Special Education Teacher
Occupational Therapist
Speech Therapist
Paraprofessional
Additional Information
Anything else we should know?
Relevant Records
Upload current IEP, recent assessments, and relevant records.
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