Lane Education Service District AAC Referral Form
Thanks for taking the time to complete this AAC referral form so we can get started on the AAC Evaluation. AAC is Augmentative Alternative Communication. If you have questions or need help filling out this form, please email us at aac@lesd.k12.or.us.   For details about the Lane ESD’s AAC Philosophy please visit our website: https://www.lesd.k12.or.us/se/slp/aug-alt-comm.html
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Student Name 
Today's Date *
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Student DOB
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Date of last IEP
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Student Home District 
School attending
Teacher Name 
Parent/Guardian Name
Phone number for Parent/Guardian 
Email for Parent/Guardian
Your Name
Your Job Title
Your email address
Your phone number
Student current Eligibility (check all that apply)
Medical Diagnosis or conditions
What is the student's level of receptive language? (Check all that apply)
How is the student currently communicating? (check all that apply)
Reading grade 
Writing grade
Speech level
Clear selection
Current device or system
What are some reinforcers for this student? Does your student have items, people, or activities that motivate them?
Briefly state why this referral is being made
Please share anything else that would be helpful for us to know.  *
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