i-Communicate app
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Student's Name
First Name
Last Name
Grade
Please Select
PK
K
1
2
3
4
5
6
7
8
9
10
11
12
12+
County
Dubois
Spencer
Perry
Pike
Which Dubois County School Corporation?
Please Select
GJCS
SWD
NED
SED
Which Spencer County School Corporation?
NS
SS
Which Perry County School Corporation?
CA
TC
PERRY CENTRAL
Which Greater Jasper School?
Please Select
Jasper Elementary
Ireland
Jasper High
Jasper Middle
Holy Trinity East(HF)3-8
Holy Trinity(PB)P-2
Which Southwest Dubois School?
*
Please Select
Huntingburg Elem
Holland Elem
Southridge Middle
Southridge High
Which Northeast Dubois School?
*
Please Select
Dubois Elem
Celestine Elem
Dubois Middle
Northeast Dubois High
Which Southeast Dubois School?
*
Please Select
Ferdinand Elem
Pine Ridge Elem
Cedar Crest Elem
Forest Park Jr/Sr High
Which North Spencer School?
*
Please Select
Chrisney Elem
David Turnham Elem
Lincoln Trail Elem
Nancy Hanks Elem
Heritage Hills Middle
Heritage Hills High
Which South Spencer School?
*
Please Select
Rockport Elem
Luce Elem
St. Bernard
South Spencer Middle
South Spencer High
Which Cannelton School?
*
Please Select
Cannelton Elem
Cannelton Jr/Sr High
Which Tell City School?
*
Please Select
William Tell Elem
William Bennett Early LC
Tell City Jr/Sr High
Which Perry Central School?
*
Please Select
Perry Central Elem
Perry Central Jr/Sr High
Which Pike County School?
*
Please Select
Petersburg Elem
Winslow Elem
Pike Central Middle
Pike Central High
Please select disability areas
Autism Spectrum Disorder
Blind or Low Vision
Mild Intellectual Disability
Moderate Intellectual Disability
Severe Intellectual Disability
Deaf or Hard of Hearing
Deaf-Blind
Developmental Delay
Emotional Disability
Multiple Disabilities
Orthopedic Impairment
Other Health Impairment
Specific Learning Disability
Traumatic Brain Injury
Language Impairment
Speech Impairment
Current Educational Setting
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Describe current communication modes
Select all current communication modes that apply
non-verbal
gestures
sign
vocalizations
words
sentences
echolalia
AAC
Other
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Describe examples of methods tried in the past
Select all examples of methods tried in the past that apply
picture exchange/PECS
Words For Life/LAMP
low tech/picture boards
eye gaze
Other
Why do you believe these methods were unsuccessful?
(i.e. lack of training, carry over, etc)
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Consider Behaviors and Limitations
Does this child have behaviors?
Yes
No
Please explain the behaviors:
Does this child demonstrate sensory, fine motor, or gross motor limitations?
Yes
No
Please explain the limitations:
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What are your expectations of an Intensive Communication Intervention?
Select all your expectations of an Intensive Communication Intervention that apply
trainings
explore different AAC options
evaluation to purchase device from Medicaid?
Other
Your Name
First Name
Last Name
Your email address
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