Assistive Technology Solutions Assessment

Assistive Technology Solutions Assessment

Please complete this form to help us understand your needs and recommend suitable assistive technology solutions.
Individual's Name

First NameLast Name
Individual's Date of Birth

MonthDayYear
Date
DDS Number
Referring Person's Name

First NameLast Name
Referring Person's Email Address
example@example.com
Referring Person's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method

Other
Point of contact during the assessment (If different from referring person)

First NameLast Name
Point of Contact Email Address
example@example.com
Point of Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Individual's Emergency Contact Name (If different from referring person)

First NameLast Name
Individual's Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Individual's Emergency Contact Relation
What agency is the individual currently supported by?
DDS Case Manager Name

First NameLast Name
DDS Case Manager Email Address
example@example.com
DDS Case Manager Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please select the primary area(s) where assistive technology support is needed.

Other
Please indicate the environments where assistive technology is needed.

Other
Please describe the individual's current disability, challenge, or condition (optional).
Does the individual currently use any assistive technology devices or solutions?
If yes, please list the assistive technology devices or solutions they currently use.
Please list the current availability for assessments.
Where is the preferred location for assessments? (Select all that apply).

Other
What are theprimary goals or needs for assistive technology? (e.g., increased independence, improved communication, better mobility)
Please indicate the preferences for assistive technology solutions (e.g., portability, ease of use, compatibility with other devices).
Is there any other information or specific request you would like us to consider?
Please upload the IP / LON Summary / LON Score here

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By signing below, I confirm that I have obtained authorization from the individual and/or their legal representative to submit this referral on their behalf. I understand that the information provided will be used to assess the needs and recommend appropriate assistive technology solutions. I consent to the use of this information for this purpose.
Signature (Please sign below to confirm your consent and the accuracy of the information provided.)
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