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, you should receive an automated response of your answers. Please allow 5 school days for a PATINS specialist to contact you about next steps.
Email address *
Referring Staff Name *
Your answer
Referring Staff Position *
Your answer
Staff Phone Number *
Your answer
Student's Name *
Your answer
Student's Age *
Your answer
Student's Grade *
Student's Initials (First and Last) *
Your answer
Student's School District *
Your answer
Student's School *
Your answer
Student's School Address *
Your answer
What Graduation Track is this student following? *
Was this student marked as having "No Mode of Communication" (NMC) on the most recent state assessment? *** PreK-2 and after 10th grade is "Not Applicable" *
Is this referral a result of the student being marked as having No Mode of Communication (NMC) for three years as a result of IDOE policy? *
Medical diagnosis, if any *
Your answer
What do you hope to accomplish with this consultation? *
Your answer
What would be your anticipated next steps after this consultation? *
Your answer
Describe Student's Schedule (full day, half day, gen ed, self-contained, therapies, activities, etc.) *
Example: "X is in self-contained class 8:30-11:20, lunch from 11:20-12:00, gen ed related arts 12-3. speech 1x a month, PT 1x month, leaves early on Wednesdays for music therapy"
Your answer
Does this student have documented vision concerns? *
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