Assistive Technology Referral Form
Please take a minute and fill out the following questions regarding the student.

Someone from the AT team will contact you to determine the next steps based on the information you provide in this form. Next steps could include any of the following:
1. A classroom observation of the student.
2. Training on assistive technology for the IEP team.
3. Provision of equipment or licenses to trial with the student.
4. A formalized evaluation

Let us know if you have any questions regarding the referral by emailing us at patt@provo.edu

Thank you!
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Email *
Student's first and last name, and nickname if any *
Student's birthdate *
MM
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DD
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School student attends? *
Teacher's name *
Does the student currently have an IEP or 504 plan in place? *
Required
Have you discussed an assistive technology referral with the student's parent? Permission may need to be obtained if the student needs a full evaluation. *
Does the student and/or parent have special communication or language needs (deafness, visual impairments, English as a second language, etc.)? If so, please indicate preferred accommodations (i.e., ASL interpreter, braille, interpreter present, and/or printed versions of information in preferred language, etc.) *
What does the student need to be able to do that is difficult or impossible to do at this time? *
What are the IEP/504 objectives related to this need? *
What are the student’s special needs that contribute to the concerns listed above? *
What are the student’s abilities related to these concerns? What are the student’s interests? *
What has been done to support the student previously? Please briefly explain:
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