ASSISTIVE TECHNOLOGY

AUGMENTATIVE & ALTERNATIVE COMMUNICATION

SERVICE REQUEST FORM

Fax this form back to: Carrie Macy65 Tower Road

San Mateo, CA 94402-4035

Fax: 650 573-4056

Or Pony to: Carrie MacyECE Center, San Mateo

Please check type of service you are requesting:

Check Appropriate Box

Assessment AT AAC**

Screening (needs assessment) AT AAC

Equipment Rental, with programming, training & support AT AAC

Training ***

Equipment Software Hardware AT/AAC Strategies AT AAC

Inventory of technology needs AT AAC

Troubleshooting AT AAC

Reviewing student previously assessed for an update of needs AT AAC

District Service for student with identified AT/AAC needs  AT AAC

Software/Hardware Loan and support AT AAC

Other (consult) AT AAC

* AT devices to assist a person with a disability to access their curriculum

** AAC teaching non-speech, motes of communication

 Available as staff permits

Student Name (if applicable):

Contact Person:District:

Phone:Times to Call:

School Site:Phone:

Assessed by SMCOE AT Specialist? Yes No Date Assessed:

Districts will be billed at a cost of $100.00 per hour per AT Specialist (including travel/office time).
***Training (up to 10 in attendance - 11-20 attendance requires a 2nd trainer)

Approved by District Special Education Director or SMCOE Program Manager:

______

Print Name

______

Signature Date

ASSISTIVE TECHNOLOGY

AGUMENTATIVE & ALTERNATIVE COMMUNICATION

(AT/AAC)

REFERRAL REQUIREMENT CHECKLIST

ECE OFFICEStudent Name:

65 TOWER ROADDate of Birth:Chronological Age:

SAN MATEO, CA 94403Current School Site:

Phone: 650 573-4010District:

FAX: 650 573-4058Program:

Description / Required/Desired / Notes
Service Request Form / R
Current Signed Assessment Plan / R
Assistive Technology Packet** / R
Current Annual IEP and Amendments / R
Speech and Language Evaluation / R
Audiogram (if applicable) / D
Vision Evaluation (if applicable) / D
OT Report (if applicable) / R
PT Report (if applicable) / R
APE Report (if applicable) / D
Outside Agency Report (if applicable) / D
Psychoeducational Report (if applicable) / D
Other / D

**AT/AAC PACKETS AVAILABLE AT ECE OFFICE (SEE ABOVE)

Send to the attention of Carrie Macy

Student Services Division

65 Tower Road  San Mateo, CA 94402  (650) 573-4010  Fax (650) 573-4056