Current DEVICE Use. [Check all that apply] The Student Uses This Device: At school At Home For Word Processing For Leisure Other iPad ☐ ☐ ☐ ☐ Chromebook ☐ ☐ ☐ ☐ Tablet ☐ ☐ ☐ ☐ Laptop ☐ Mac and/or ☐ PC ☐ ☐ ☐ ☐ AAC: List Device ☐ ☐ ☐ ☐ Other: List Device ☐ ☐ ☐ ☐ Other: List Device ☐ ☐ ☐ ☐ Consultation Services Requested ☐ Training ☐ student ☐ school staff ☐ family ☐ Instructional supports ☐ math ☐ reading ☐ writing ☐ life skills ☐ communication ☐ other __________________________________ ☐ Order ☐ facilitate process for ordering recommended AT ☐ Other Please list services needed: Area Cooperative Educational Services ACES Staff Development/Administration Building 000 Xxxxx Xxxxxx Xxxxxx, Xxxxxxxxxxx 00000 000-000-0000 (voice) 000-000-0000 (fax) Parental Input and Information Form Your child has been referred by the educational team for an assistive technology assessment or consultation. This information will help the consultant provide appropriate assistive technology suggestions to the team. District: Date: Student’s Name: DOB: Name of Parent/Guardian: Parent Email/Phone Number: What tasks/activities/skills would you like to see improvement in as a result of this assistive technology assessment? Provide examples of tasks/activities that are difficult for your child currently: What are your short-term goals for your child? What are your long-term goals for your child? Relevant Medical Information/Diagnoses: If your child has behaviors that impact learning, please describe: Parent/Guardian – 1 of 2 Please tell us about your child. For example, their interests, hobbies, strengths and personality. What do we need to know about your child? Child’s Communication Abilities: Child’s Functional (self-care), Physical and Positioning Abilities: Assistive Technology previously tried: Assistive Technology used at home (e.g. type of computer, equipment, adaptations): Other information you would like to share: Your input is appreciated in assisting the team to help your child. A report will be generated when the evaluation or consultation is completed for PPT review. Please return this completed form to: Xxxx Xxxxxxxx, Director ACES Assistive Technology Services 000 Xxxxx Xxxxxx Xxxxxx, XX 00000 FAX: (000) 000-0000 Parent/Guardian – 2 of 2 or via email XXxxxxxxx@xxxx.xxx.
Current DEVICE Use. [Check all that apply] The Student Uses This Device: At school At Home For Word Processing For Leisure Other iPad ☐ ☐ ☐ ☐ Chromebook ☐ ☐ ☐ ☐ Tablet ☐ ☐ ☐ ☐ Laptop Mac☐ or PC☐ ☐ ☐ ☐ ☐ AAC: List Device ☐ ☐ ☐ ☐ Other: List Devices ☐ ☐ ☐ ☐ Other: List Devices ☐ ☐ ☐ ☐ Current Assistive Technology Used [complete all applicable sections] Assistive Technology Device Type and/or Manufacturer/Model and/or Platform/Operating System Features e.g. screen enlargement, voice output, special switches, word prediction Computer Chromebook iPad or Similar Device Commonly Used Apps Manual Communication Board Augmentative Communication Device Vision Aids Amplification System Manual Wheelchair Power Wheelchair Adapted Classroom Chair Ambulation Aids Alternative Positioning Equipment Writing Aids Environmental Control/Adapted Toys Educational Software Other: Referral Info – 2 of 4 Information to Guide AT Evaluation Process List the questions you want addressed by an assistive technology assessment/referral. (Ex: How can grade level reading material be accessible to student with a reading level of *?
Current DEVICE Use. [Check all that apply] The Student Uses This Device: At school At Home For Word Processing For Leisure Other iPad ☐ ☐ ☐ ☐ Chromebook ☐ ☐ ☐ ☐ Tablet ☐ ☐ ☐ ☐ Laptop Mac☐ or PC☐ ☐ ☐ ☐ ☐ AAC: List Device ☐ ☐ ☐ ☐ Other: List Devices ☐ ☐ ☐ ☐ Other: List Devices ☐ ☐ ☐ ☐ Current Assistive Technology Used [complete all applicable sections] Assistive Technology Device Type and/or Manufacturer/Model and/or Platform/Operating System Features e.g. screen enlargement, voice output, special switches, word prediction Computer Chromebook iPad or Similar Device Commonly Used Apps Manual Communication Board Augmentative Communication Device Vision Aids Amplification System Manual Wheelchair Power Wheelchair Adapted Classroom Chair Ambulation Aids Alternative Positioning Equipment Writing Aids Environmental Control/Adapted Toys Educational Software Other: Referral Info – 2 of 4 Information to Guide AT Evaluation Process What is the functional area of concern? What does the student need to be able to do that is difficult or impossible to do independently at this time that prohibits progress on IEP objectives listed above? (Example: Student needs to be able to take notes independently in his/her regular education classroom, Student needs to independently communicate his need to use the bathroom to various staff members.)
