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Assistive Technology Evaluation Request Form
Thank you for choosing AAC & Me, LLC to support your student's communication and learning needs!
Please complete this evaluation request form in its entirety to formally request an evaluation for your student.
Your assigned evaluator will contact you upon receipt of this form to discuss your student's needs in further detail. Your evaluator will then collaborate with you to schedule the evaluation.
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* Indicates required question
Email
*
Your email
District Requesting Service
*
Your answer
Referring Professional's Information
Please answer these questions about yourself, as the individual requesting the evaluation.
Name of Individual Submitting Request
*
Your answer
Your Role Within Your District
*
Case Manager
Director of Special Education
Secretary of Child Study Team
Other:
Case Manager Contact Information
If you are not the student's case manager, please include their name and contact information in the spaces provided.
Case Manager's Name
Your answer
Case Manager's Email
Your answer
Student Information
Please have student's information available to quickly and successfully complete this portion of the evaluation request form.
Student's Full Name
*
Your answer
Student's Date of Birth
*
MM
/
DD
/
YYYY
Student's Classification
*
Auditory Impairment
Autism
Communication Impairment
Emotional Regulation Impairment
Intellectual Disability
Multiple Disabilities
Orthopedic Impairment
Other Health Impairment
Preschool Child with a Disability
Specific Learning Disability
Traumatic Brain Injury
Visual Impairment
Student's Grade/Class
*
Your answer
Name of School Student Currently Attends
*
Your answer
Is this an Out of District Placement?
*
Yes
No
Student's Medical/Speech Diagnosis (if any)
*
Your answer
Primary Language
Your answer
Rationale for Evaluation Request
The following questions will help the evaluator gauge what areas of learning the student experiences challenges with, in order to best prepare for the evaluation. It would be helpful to know any current accommodations or assistive technology supports in place for the student, if applicable.
Check all applicable boxes of which your student may be demonstrating weaknesses when accessing the academic curriculum:
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Decoding
Reading Comprehension
Spelling
Composing Written Material
Executive Functioning
Alternative Access (finding alternative ways for a student to interact with technology due to significant motor or physical impairment)
Vision
Hearing
Other:
Required
Please provide a brief description of the student's learning challenges, as well as any relevant medical/developmental or academic history that you believe the evaluator should be aware of.
*
Your answer
Current Assistive Technology supports (if any)
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Does the student already have access to, or perhaps, trialed, any assistive technology tools or supports (e.g.: audiobooks, voice typing, various Chrome extensions, etc.)
Please list any strategies or supports trialed or accessed, if applicable.
Your answer
Please provide any additional information that you believe would be helpful for the evaluator to consider, if not mentioned already. Thank you!
Your answer
Please send a copy of the student's IEP to: gabriella@aac-me.com
*
I have already submitted the IEP to the email provided
I will send the IEP as soon as I complete this form
A copy of your responses will be emailed to the address you provided.
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