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AT Evaluation Referral form*
***Signed consent is required before completing this form.
***Please note that limited availability of technology/chromebooks in school does NOT warrant an AT evaluation.
***AT Evaluations are NOT warranted if the student is getting an initial IEP- you must allow specialized instruction to be attempted with accommodations and modifications as needed. An AT Consult may be requested on an established IEP if there is no AT on page 8. If a student with an established IEP has AT on page 8 and is still not making satisfactory progress on content area objectives (not behavioral or fine motor), then an AT Evaluation may be determined per PPT Team.
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Email *
Student Name *
Person (s) completing this form( team can complete one form together) include email also.  *
 Current Case Manager and location *
Date of Birth *
Student's grade *
Student's Current School *
PPT Date *
MM
/
DD
/
YYYY
Student's Case Manager *
Primary Disability *
Primary Language *
Is this student moving schools? Where and when?
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