Autism Consultation Request
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Building: *
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Phone Number: *
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Email: *
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STUDENT SPECIFIC INFORMATION
Student Name: *
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Student Age: *
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Student Grade: *
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Classroom Teacher: *
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Does the student have an IEP?
Eligibility and/or medical diagnosis:
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Related Services/mpw:
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Current Placement:
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Previous Placements/Academic History:
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Has the student received any specialized consultation previously? If so, please describe:
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Students approximate cognitive functioning and/or academic level:
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Current mode of communication:
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Current Medications:
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Current Reinforcers/Motivation:
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What are the two most important questions your team would like answered from this consultation? (other than Autism considerations)
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What strategies and/or adaptations are presently in place?
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Please list tasks, items, or people that are problematic for the student:
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Other student information:
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Student's Class Schedule: *
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