JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
 Request Assistance from the LADSE AT Team
Complete this form to request an assistive technology evaluation or consultation.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Contact Person
*
Your answer
Student
*
Your answer
Students Birthdate
*
MM
/
DD
/
YYYY
School/Grade
*
Your answer
Home School District
*
Butler 53
Darien 61
Gower 62
Westchester 92.5
Komarek 94
Brookfield 95
Riverside 96
Western Springs 101
LaGrange North 102
Lyons 103
Lagrange South 105
Highlands 106
Pleasantdale 107
LTHS 204
RBHS 208
Other:
What service are you requesting?
*
Evaluation with domain
Evaluation, no domain opened
Consultation
Training
Required
Main Area To Be Addressed
*
Choose
Communication
Access
Writing
Reading
Math
Executive Functioning
Positioning
Other Information...
Your answer
Has a domains been opened? (optional)
*
Yes
No
Has the District Special Education Director/ Program Coordinator provided approval?
*
Yes
No
Have the parent(s) been informed?
Yes
No
Preferred meeting dates/times
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of La Grange Area Department for Special Education.
Report Abuse
Forms
