PATINS AAC Consultation Form
Thank you for your interest in PATINS consultation related to Augmentative & Alternative Communication. Our consultation services are for Indiana PreK-12 public schools. After filling out this form for each student, you should receive an automated response of your answers. Please allow 5 school days for a PATINS specialist to contact you about the next steps.

Again: Only one student per submission and only Indiana public school/cooperative staff can submit, we cannot accept incorrectly filled out requests.
If you have any questions, please email Jessica Conrad jconrad@patinsproject.org or David Jackson djackson@patinsproject.org
Email address *
Referring Staff Name *
Must be an Indiana public PreK-12 staff member (LEA, public charter school, cooperative)
Referring Staff Position *
Other Team Members and emails
Staff Phone Number *
Student's Name *
Only one student per submission will be accepted. Please do not submit more than one student on one form.
Student's Age *
Student's Grade *
Student's Initials (First and Last) *
Student's School District *
Student's School *