ASSISTIVE TECHNOLOGY
AUGMENTATIVE & ALTERNATIVE COMMUNICATION
SERVICE REQUEST FORM
Fax this form back to: Carrie Macy
Or Pony to: Carrie Macy
Please check type of service you are requesting:
65 Tower Road
San Mateo, CA 94402-4035
Fax: 650 573-4056
ECE Center, San Mateo
Assessment
Screening (needs assessment)
Equipment Rental, with programming, training & support
Check Appropriate Box
AT
AT
AT
AAC**
AAC
AAC
Training ***
Equipment Software Hardware AT/AAC Strategies AT
Inventory of technology needs
Troubleshooting
AT
AT
AT Reviewing student previously assessed for an update of needs
District Service for student with identified AT/AAC needs

Software/Hardware Loan and support
Other (consult)
* AT devices to assist a person with a disability to access their curriculum
** AAC teaching non-speech, motes of communication

Available as staff permits
Student Name (if applicable):
Contact Person:
Phone:
School Site:
District:
Times to Call:
Phone:
AT
AT
AT
AAC
AAC
AAC
AAC
AAC
AAC
AAC
Assessed by SMCOE AT Specialist? Yes No Date Assessed:
Districts will be billed at a cost of $100.00 per hour per AT Specialist (including travel/office time).
***Training (up to 10 in attendance - 11-20 attendance requires a 2 nd
trainer)
Approved by District Special Education Director or SMCOE Program Manager:
____________________________________________
Print Name
____________________________________________
Signature
_________________
Date
Student Services Division
65 Tower Road

San Mateo, CA 94402

(650) 573-4010

Fax (650) 573-4056

ASSISTIVE TECHNOLOGY
AGUMENTATIVE & ALTERNATIVE COMMUNICATION
(AT/AAC)
ECE OFFICE
65 TOWER ROAD
SAN MATEO, CA 94403
Phone: 650 573-4010
FAX: 650 573-4058
REFERRAL REQUIREMENT CHECKLIST
Student Name:
Date of Birth:
Current School Site:
District:
Program:
Chronological Age:
Description
Service Request Form
Required/
Desired
R
Notes
Current Signed Assessment Plan
Assistive Technology Packet**
R
R
Current Annual IEP and Amendments
Speech and Language Evaluation
Audiogram (if applicable)
Vision Evaluation (if applicable)
R
R
D
D
OT Report (if applicable)
PT Report (if applicable)
APE Report (if applicable)
Outside Agency Report (if applicable)
Psychoeducational Report (if applicable)
Other
R
R
D
D
D
D
**AT/AAC PACKETS AVAILABLE AT ECE OFFICE (SEE ABOVE)
Send to the attention of Carrie Macy
Student Services Division
65 Tower Road

San Mateo, CA 94402

(650) 573-4010

Fax (650) 573-4056