Assistive Technology Referral Form
Student: Date Submitted:
D.O.B. Age: Grade:
Disability: Placement: Referred By:
Parent's Names:
Special Education Teacher: Occupational Therapist:
General Education Teachers: Physical Therapist:
Speech Therapist: Vision Specialist:
Problem Identification: (Please specify classes in which the student is demonstrating deficits that prompted
this referral)
1. What task(s) is the student unable to do at a level that reflects hsi/her skills/ abilities?
2. Please check the areas of concern for this student as they relate to the referral concern:
Behavior Communication Handwriting
Spelling Written Language Computer Access
Student Number:
Street Address: Phone Number::Zip Code
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2a. Please write a brief narrative of your observations for each area checked:
3. What is the academic performance level of the student? Include current grades/performance.
Reading: Language Arts:
Social Studies:
4. Please describe the student's strengths, learning style(s), compensatory skills, interests, and any other
pertinent factors.
5. What strategies have been tried to address the problem? Please include curriculum adaptations,
instructional modifications, assistive technologies, etc.
6. Of these strategies, what has shown promise of success?
7. What aspect of your strategies has not been successful?
8. What other resources have been used to date to help address the problem? (outside evaluations and/or
therapy, community resources, etc.
Technology Resources: Please provide information regarding technology availability:
1. What type of computers or technology are now available for student use?
2. Where are they located? Please indicate computer name and asset tag numbers.
3. If the student is currently using a computer or another piece of technology, please indicate how often, for
how long, in which settings, and for what types of assignments is it being used.
IEP Team use only:
No AT device or service is recommended at this time by the IEP team.
Current AT device or services are meeting the student's needs.
Refer to Assistive Technology Specialist for further evaluation.
For Assistive Technology Team Use only:
Date Received from the IEP committee:
Date Parent signed A.T. permission: form
Date of the A.T. planning meeting:
Date of next A.T. review:
Date forwarded back to the IEP committee:
A.T. team contact: