Assistive Technology Consultation Form
| Contact Information | ||
| Referral Contact: | Agency/School: | |
| Street: | ||
| Town/City: | State: | Zip Code: |
| Telephone: | Fax Number: | |
| Email: | ||
| Learner Name: | Age: | |
| Web Site: | www.PracticalATSolutions.com |
| E-mail: | Phyl@PracticalATSolutions.com |
| Telephone: | (802) 484-3537 |
| Consultation Areas | Description of Needs | |
| Adapted Curriculum & Teaching | |
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| Augmentative Communication | |
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| Collaborative Team Building | |
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| Control Interfaces & Switches | |
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| Education & Vocational Supports | |
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| Environmental Design & Accomodations |
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| Keyboard & Mouse Emulation | |
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| Specialized Software Applications | |
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| Other (please explain) | |
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| Web Site: | www.PracticalATSolutions.com |
| E-mail: | Phyl@PracticalATSolutions.com |
| Telephone: | (802) 484-3537 |
| Consultation Contact | ||
| Name: | Agency/School: | |
| Street: | ||
| Town/City: | State: | Zip Code: |
| Telephone: | Fax Number: | |
| Email: | ||
| Consultation Goals |
| (Please be Specific) 1. |
| 2. |
| 3. |
| Referral Apprival | ||
| Administrator: | Agency/Supervisory Union: | |
| Street: | ||
| Town/City: | State: | Zip Code: |
| Telephone: | Fax Number: | |
| Administrator Email: | ||
| Administrator Signature (required) | Date | |
| Web Site: | www.PracticalATSolutions.com |
| E-mail: | Phyl@PracticalATSolutions.com |
| Telephone: | (802) 484-3537 |