Assistive Technology Consultation Request Form

Sheboygan Area School District
Request for Consultation
Assistive Technology/Augmentative Communication
Case manager:
Referring Teacher/Team Member:
Reason for referral (What problem needs to be addressed, evaluated, or remediated?)
Student information:
Disability: (Check all that apply)
 Autism
 Hearing Impaired
 Orthopedic Impairment
 Visual Impairment
 Cognitive Disability
 Hearing Impairment
 Other Health Impairment
 Emotional Behavioral Disturbance
 Specific Learning Disability
 Traumatic Brain Injury
 Speech/Lang. Impairment
 Significant Developmental Delay
Classroom Setting: (Check all that apply)
 General Education Classroom
 Self-Contained Classroom
 Resource Room Support
 Other:
Current Related Services Received:
 Itinerant DHH
 Itinerant Vision
 Orientation & Mobility
 Occupational Therapy
 Physical Therapy
 Speech/Language
Is the student’s disability stable or changing?
If fine &/or gross motor skills are inadequate, please describe.
What is the student’s level of participation in classroom?
Describe the family’s expectations for technology support.
What is the student’s current grade / age level of performance in:
Written Language
Oral Language
 Math
If Augmentative Communication Referral:
Describe communication methods currently used by the student:
How well do others understand these methods:
Does the child initiate communication? How and with whom?
Computer Assisted Technology:
Does the student have access to a computer:  in gen ed. class  in special ed. class
 computer lab
What software does the student use?
How is the software used? (free time, curriculum access, etc.)
at home
What technology do you currently have for the student to access?