Sheboygan Area School District Request for Consultation Assistive Technology/Augmentative Communication Student: Birthdate: / Teacher: Case manager: School: Grade: / ID# 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: Reading 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?