Assistive Technology Solutions Assessment
Please complete this form to help us understand your needs and recommend suitable assistive technology solutions.
Individual's Name
*
First Name
Last Name
Individual's Date of Birth
*
-
Month
-
Day
Year
Date
DDS Number
*
Referring Person's Name
*
First Name
Last 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
Email
Phone
Text Message
Other
Point of contact during the assessment (If different from referring person)
First Name
Last 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 Name
Last 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 Name
Last 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.
*
Communication
Mobility
Vision
Hearing
Learning/Cognition
Daily Living
Other
Please indicate the environments where assistive technology is needed.
*
Home
School
Workplace
Community
Other
Please describe the individual's current disability, challenge, or condition (optional).
Does the individual currently use any assistive technology devices or solutions?
*
Yes
No
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).
*
Home
MARC, Inc. of Manchester office
Day program / workplace
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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Signature (Please sign below to confirm your consent and the accuracy of the information provided.)
*
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