AAC Training or Consultation Request Form

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Thank you for choosing AAC & Me, LLC to support your student's communication needs!

Please complete this Training and Consultation request form in its entirety to formally request an evaluation for your student.

Please note the differences between a Training vs. a Consultation Request:

AAC Training - Select this option if the student was recently evaluated by AAC & Me, LLC and requires a team and family training on the newly acquired technology that was recommended in the recently completed evaluation report. Think: Educating, Review, Building Knowledge
AAC Consultation - This option should only be selected if an AAC & Me Clinician has previously worked with or trained the student's staff members, student, and/or family. Think of this more as a "follow-up", as opposed to an "introduction". Think: Problem Solving, Fine Tuning, Guidance

Your assigned consultant will contact you upon receipt of this form to schedule your requested service.

Email *

District Requesting Service *

Referring Professional's Information

Please answer these questions about yourself, as the individual requesting the evaluation.

Name of Individual Submitting Request *

Your Role Within Your District *

Case Manager

SLP

Director of Special Education

Secretary of Child Study Team

Other

Contact Email *

Contact Phone Number

Student Information

Please have student's information available to quickly and successfully complete this portion of the evaluation request form.

Student's Full Name *

Student's Date of Birth *

YYYY

Student's Classification *

Autism

Deaf-Blindness

Deafness

Emotional Regulation Impairment

Hearing Impairment

Intellectual Disability

Multiple Disabilities

Orthopedic Impairment

Other Health Impairment

Preschool Child with a Disability

Specific Learning Disability

Speech or Language Impairment

Traumatic Brain Injury

Visual Impairment

Student's Grade/Class *

Name of School Student Currently Attends *

Is this an Out of District Placement? *

Yes

Student's Medical/Speech Diagnosis (if any) *

Type of Service Requested *

Post-Evaluation AAC Training

Follow Up AAC Consultation

Any relevant updates or changes regarding the student that may impact their communication skills since last seen by an AAC & Me Clinician?

A copy of your responses will be emailed to the address you provided.

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