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Request for Assistive Technology Services
Hill County Shared Services Arrangement
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* Indicates required question
Email
*
Your email
Request Made By:
*
Your answer
Campus
*
Choose
Abbott
Aquilla
Bynum
Covington
Gholson
Hubbard Elementary
Hubbard MS
Hubbard HS
Itasca Elementary
Itasca MS
Itasca HS
Malone
Mt. Calm
Penelope
Whitney Elementary
Whitney MS
Whitney HS
Daycare
SSA
Student's Grade Level/Age
Your answer
Type of Service Requested
*
Student Consultation
Student Evaluation (Will ONLY be completed subsequent to a Student Consultation)
Classroom Consultation
Device Technical Support
Training for Staff
Other:
Required
Preferred Date/Time of AT Service
Note, this does not guarantee AT team will be available during this time slot. This is to assist in scheduling.
MM
/
DD
/
YYYY
Time
:
AM
PM
If you would like us to work with someone else to schedule this service, please provide their contact information. (Name, Position, School, Email, Phone Number, etc.)
Your answer
Any other questions or comments
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