Assistive Technology Parent Questionnaire
AT Solutions LLC
Directions: Please fill out the form below. Skip any N/A questions.
Student Name
First Name
Last Name
Name of person completing form
First Name
Last Name
School District
Parent Contact Information (Save after each entry)
*
What would you like to see your child do that he/she cannot do now?
What assistive technology, supports, or strategies have you already tried?
What type of computer equipment is available at home? Check all that apply
Windows Laptop
Windows Desktop
Macintosh Laptop
Macintosh Desktop
iPad
Surface Pro
Chromebook (Family Owned)
Chromebook (School Owned)
Kindle
Cell phone (Student Owned)
How often does your child use a computer for...
Rows
Daily
3-4 times/
week
2-3 times/
week
Never
Homework
Games
Internet
Email
Social Networking
What are your child's interests?
Please include any other important information that you would like to share about your child.
Submit
Should be Empty: