Referral for Assistive Technology Assessment
(Must be approved by Building Level CSE)
*Please return this form and student IEP/504 Plan to:
Cheryl Button, Smith School, TST BOCES
I. REFERRAL DATA
Student Name: ___________________________
Age/DOB: _______________
School District: __________________________
School: __________________
Grade/Placement: __________________
Teacher: ________________________
Teacher Phone/Email: ________________________________________________
Parent/Guardian: ______________________ Phone: ________________________
Please Select one
Initial Referral: _________
Re-evaluation:_________
*Signature of Building CSE Chairperson: _________________________
(Required)
Does student have an IEP or 504 Plan? _____________
Consultation: _________
Date: ________________
CSE Classification _____________
Is this referral for Communication Concerns? ________________
II. REASON(S) FOR REFERRAL:
A. Presenting problems/difficulties (Please describe how the presenting problem interferes with reaching educational
goals):
B. Description of student’s goals/needs that could be assisted by technology. What tasks are under
consideration e.g. communication, reading, writing, etc? :
Revised 1/9/13
III. STUDENT BACKGROUND
For relevant domains, please describe the student’s level of functioning in regards to the current
technology request. Only address applicable areas. Do not restate what is on IEP.
A. Cognitive Abilities (cause/effect, relationships, matching, identification, categorization, sequencing, association,
memory, and comprehension) Think in terms of current technology request:
B. Motoric Abilities (mobility, range of motion, strength, fatigue level, tactile sensitivity, and fine and gross motor abilities)
Think in terms of current technology request:
C. Sensory Abilities (visual and hearing abilities) Think in terms of current technology request:
D. Communication Skills (verbal, vocal, sign, gesture, language board, communication device), making requests, and
indication of choices or preferences. If the student uses a language board or communication device, please indicate the
symbol system and the symbol selection mode) Answer this section only if this referral is requesting a Speech
Generating Device:
E. Behavioral Factors (attach FBA/BIP if available, perseveres beyond desired point, active resistance, passive resistance,
manipulative behaviors, physical involvement such as tremors or spasticity, fatigue) and Motivational Factors (persons,
food, objects, activities, sound, other) Think in terms of current technology request:
F. Technology (history of technology used to address the problems/difficulties and success of those strategies):
Revised 1/9/13
IV. INTERVENTIONS
A. What other possible solutions have you considered and the student’s response to intervention?
(Academic Intervention Services, Response To Intervention, Read 180, etc.):
V. SCHOOL ENVIRONMENT:
A. Please list all hardware, software, and peripherals this student currently uses or may have access
to in the building.
B. Name(s), Title(s), Phone number(s), Email(s) of contact people in the district:
(All persons involved actively with the student’s educational program, including therapists, aide, etc. These are the
individuals who will receive a copy of the evaluation report).
Title
Building CSE Chair
General Ed. Teacher
Special Ed. Teacher(s)
AIS Teacher
Psychologist
Occupational Therapist
Speech Therapist
Reading Teacher
Parent/Guardian
Other (specify)
Name
Phone
Email
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C. Additional Comments:
Revised 1/9/13