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ASSISTIVE TECHNOLOGY INTAKE INFORMATION FORMSchool-Based ServicesCurriculum AccessDate: FORMTEXT ????? IDENTIFYING INFORMATION Student Name: FORMTEXT ?????Date of Birth: FORMTEXT ?????Age: FORMTEXT ?????Gender: FORMTEXT ?????Address: FORMTEXT ?????Parents/Guardians: FORMTEXT ?????Telephone: FORMTEXT ?????Home: ? Cell: ? Email: FORMTEXT ?????Primary language spoken at home: FORMTEXT ?????PERSON COMPLETING FORMName: FORMTEXT ?????Relationship to Student: FORMTEXT ?????Contact information:Email: FORMTEXT ?????Phone Number: FORMTEXT ?????SCHOOL INFORMATIONName of School: FORMTEXT ?????Address: FORMTEXT ?????Contact Person: FORMTEXT ?????Contact information:Email: FORMTEXT ?????Phone Number: FORMTEXT ?????REPORT Person to Receive Report: FORMTEXT ?????Preference/contact information:Email: FORMTEXT ?????Hard copy (snail mail): FORMTEXT ?????SERVICE REQUESTEDAssistive technology services include computer access, technology to support reading and writing, educational accommodations and accessibility to support curriculum access. FORMCHECKBOX AT Evaluation Working at the school directly with the student and team to help determine what technology would support the student in meeting their goals. The evaluation includes a comprehensive report. FORMCHECKBOX AT ConsultationA consultation to assist teams to understand their assistive technology choices. Can include assistance with set-up, training, and integrating device use into classroom, and attendance at IEP meetings (3-hour minimum charge per visit) FORMCHECKBOX TrainingTraining in a specific topic, such as a specific software program or teaching staff how to use support strategies (3-hour minimum charge per visit)If you have a question about services, or a student with either Augmentative Communication (AAC) needs or AT for Transition needs, please contact Kristi Peak-Oliveira at kpoliveira@DIAGNOSIS (required) FORMCHECKBOX Autism FORMCHECKBOX Brain Injury FORMCHECKBOX Hearing Impairment FORMCHECKBOX Asperger’s FORMCHECKBOX Cognitive Disability FORMCHECKBOX Mobility Impairment FORMCHECKBOX PDD FORMCHECKBOX Learning Disability FORMCHECKBOX Speech/Language FORMCHECKBOX Cerebral Palsy FORMCHECKBOX Vision Impairment FORMCHECKBOX Other FORMTEXT ?????Areas of ConcernREADINGWhat specific tasks are difficult for the student? FORMCHECKBOX Decoding FORMCHECKBOX Proof Reading FORMCHECKBOX Comprehension FORMCHECKBOX Eye Problems/Fatigue FORMCHECKBOX Reading Speed FORMCHECKBOX Other FORMTEXT ?????WRITINGWhat specific tasks are difficult for the student? FORMCHECKBOX Legibility FORMCHECKBOX Pre-writing FORMCHECKBOX Holding Writing Utensil FORMCHECKBOX Organizing Ideas FORMCHECKBOX Hand Pain or Fatigue FORMCHECKBOX Needs a Scribe (please explain) FORMTEXT ????? FORMCHECKBOX Spelling FORMCHECKBOX Other FORMTEXT ?????What would you like to see the student do that he/she cannot do now? FORMTEXT ?????What assistive technology, supports, or strategies have you already tried? FORMCHECKBOX Computer: FORMCHECKBOX Mac FORMCHECKBOX PC FORMCHECKBOX iDevice FORMCHECKBOX iPod touch FORMCHECKBOX iPhone FORMCHECKBOX iPad FORMCHECKBOX Low tech: FORMCHECKBOX slant board FORMCHECKBOX adaptive writing utensil FORMCHECKBOX Vision Aids FORMCHECKBOX page magnification FORMCHECKBOX highlighters FORMCHECKBOX more white space FORMCHECKBOX magnifiers FORMCHECKBOX CCTV FORMCHECKBOX glare filers FORMCHECKBOX Specialized Software FORMCHECKBOX talking word processor FORMCHECKBOX speech recognition FORMCHECKBOX screen magnification FORMCHECKBOX Arm or wrist support FORMCHECKBOX Adaptive Mouse FORMCHECKBOX Touch Screen FORMCHECKBOX Note taking device FORMCHECKBOX AlphaSmart Fusion Writer FORMCHECKBOX Other FORMTEXT ?????Other: FORMTEXT ?????STUDENT’S COMPUTER SKILLS: FORMCHECKBOX Good keyboarding skills FORMCHECKBOX Good mouse skills FORMCHECKBOX Types slowly FORMCHECKBOX Presses keys accurately FORMCHECKBOX Knows some letter locations FORMCHECKBOX Accidentally hits unwanted keysOther: FORMTEXT ?????What key supports/accommodations are in place to help the student overcome identified difficulties? FORMCHECKBOX Note taking FORMCHECKBOX Alternative assignments FORMCHECKBOX Short answers FORMCHECKBOX Alternative testing environment FORMCHECKBOX Homework modifications FORMCHECKBOX Extended time for testsOther: FORMTEXT ?????Are math skills an area of difficulty for the student? FORMCHECKBOX Yes FORMCHECKBOX NoMath subject/Grade level: FORMTEXT ?????Please describe any difficulties? FORMTEXT ?????Additional Information: Please include any other important details about the student. Strengths? Weaknesses? Learning Style? Interests? FORMTEXT ?????Other Service Providers: Please list any Occupational Therapy, Physical Therapy, Speech Language Therapy, ABA, TVI, etc. If these specialists should be contacted prior to the evaluation please include their contact information.Provider: FORMTEXT ?????Contact: FORMTEXT ?????Provider: FORMTEXT ?????Contact: FORMTEXT ?????Provider: FORMTEXT ?????Contact: FORMTEXT ?????Provider: FORMTEXT ?????Contact: FORMTEXT ?????Classroom Setting: FORMCHECKBOX Self-contained FORMCHECKBOX Resource room FORMCHECKBOX Regular education FORMCHECKBOX Other FORMTEXT ????? FORMCHECKBOX InclusionAdditional Information: FORMTEXT ?????PLEASE ATTACH ANY RELEVANT REPORTS – INCLUDING THE IEP - WITH INFORMATION RELATING TO COMMUNICATION, COGNITION, OR OVERALL DEVELOPMENTAL LEVEL.Once the form is completed, please return it to Easter Seals using one of the options below:Email* (preferred)atintakes@FAX: 617-737-9875Postal:Easter Seals Massachusetts89 South StreetBoston, MA 02111Attn: School IntakesPlease direct any questions to Kristi Peak-Oliveira, AT Program Manager, at kpoliveira@ or 617-226-2861Thank you for choosing Easter Seals services! ................
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