Assistive Technology Referral
This electronic form will allow you to indicate more than one area of concern and the strategies you have already trialed with your student. However, you must complete one area of deficit at a time. After each section, you will have the opportunity to select an additional area.
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Student Name: *
Date of Birth: *
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School: *
Grade : *
Primary Disability: LD *
Secondary Disability:
IQ: *
Case Manager: *
Case Manager's Email Address/ Contact Number *
Referral Completed By: *
Who is requesting this referral? *
IEP Due Date: *
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Any previous AT referrals? If so, what was the area of concern?
What is the best time of day for you to meet regarding this referral? *
If needed, what is the best time of day to pull the student? *
On which IEP goal/objective is the student unable to make progress? *
What task does the student need to do that they are currently unable to do? *
What related services does the student currently receive? *
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