3 - ATLA Referral

  • Referral

    As of May 2026, please expect a response within 4-6 weeks of contact. If you should like an update on your waiting list spot, please email atla@atlaak.org. ATLA will make three (3) attempts to get in touch. If we do not get a response after the third attempt, the case will be closed until we hear from the contact. 

  • The following information should be for the professional completing the form

  • Format: (000) 000-0000.
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  • The following information should be for the individual being referred

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Phone type:
  • Format: (000) 000-0000.
  • Phone type:
  • If ATLA needs to make contact with the individual being referred or their alternate contact, are they expecting a call from us?

  • ATLA will make three (3) attempts to reach out. If we do not get a response after the third attempt, their case will be closed.

  • If there is an alternative person we can contact in the event our specialists are unable to reach the applicant, please share their information below.

    • Click to add an alternative person to contact for referral (caregiver, service provider, family member, etc). 
    • Format: (000) 000-0000.

    • Please share information related to the applicant's assistive technology needs below.

    • Click to add assistive technology needs 
    • Possible assistive technology area(s) of need (required): (check all that apply)*
    • What is the main reason(s) for the participant being referred for AT? (check all that apply)
  • Should be Empty: