(AT) Consult Request Form
Please fill out all areas of this form:
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Email *
First Name of student *
Last Name of student *
DOB *
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/
DD
/
YYYY
Is this Consult Request a result of: *
Explain Other *
Date of PPT/504/parent meeting *
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/
DD
/
YYYY
Date you are submitting this request *
MM
/
DD
/
YYYY
PPT IEP questions *
Yes
No
I don't know
Is this student new to Danbury?
Does this student have an Assistive Technology Evaluation on record?
Does this student currently have assistive technology on Page 8
Concerns for the student in the following areas, check all that apply: *
Required
Describe student (Eligibility, vision, hearing) *
Required
School *
Grade *
Teacher/Case Manager *
Email of Case Manager *
Facilitator: *
Describe area of observed difficulty. *
What accommodations were previously tried (including accommodations listed on page 8) Check all that apply: *
Required
What GOALS and OBJECTIVES is the child not making satisfactory progress in? *
check all that apply
Related services *
Has the student's AT needs been discussed with the team and parents *
Required
Is there any other information you feel is important for the AT Team to know about with this case? (i.e. Do you need a written consult with suggestions for presentation at a PPT; when does this needs to be completed by; student comes into district with AT in the IEP but no AT evaluation is provided and former school unable to provide and/or student uses own personal device, what specific block/period needs to be observed.) *
When is best day/time to consult? *
Morning
Midday
Afternoon
Monday
Tuesday
Wednesday
Thursday
Friday
A copy of your responses will be emailed to the address you provided.
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