For IEP Team or ECAT use:

DEC 1 Date  	 DEC 2 Date  	 Current IEP Date  	 

Exceptional Children’s Program

For EC Office Use:

Date Received  	 Date Due  	

Referral Type - Check One:
Assistive Technology                    Augmentative & Alternative Communication

Identification

Student’s Name:  	   Exceptionality:  	   DOB:  	 School:  	    School Contact Person: 	 Person Making Referral: 	  Parent’s Name:  	  

Date of Referral:  		 ID#:  	
Age:  		  Grade: 	 School Phone: 		 Phone: 		 Phone:  		 

Address:  	 Student’s Primary Language:  	

Area of Concern   (Check all that apply)
Mechanics of writing                                             Math
Fine motor related to computer access                Daily living skills (e.g., environmental controls) Composing written material                                  Recreation and Leisure
Reading                                                                Communication (verbal)
Learning and Studying

What specific task(s) must the student complete that is currently difficult or impossible? (Mandatory information)

Current Placement
Birth-3	Early Childhood	Elementary	
Middle School	Secondary	Transition to Post Secondary	

Classroom Setting
Regular	Resource	Separate	
Public Separate School
Private Residential	Private Separate School
Home/ Hospital	Public Residential	

Current Related Services Received
Occupational Therapy	Physical Therapy	Speech/Language Therapy	
Special Transportation	Adaptive P.E.	Other:  		

Medical Considerations  
Visual Screening passed on ___/___/___  Hearing screening passed on ___/___/___
Comments:______________________________________________________________
History of seizures
Has degenerative medical condition (explain) 	 Has multiple health problems (explain) 		 Has frequent ear infections
Swallowing/feeding problems
Currently taking medicine for:  		 History of surgery (describe):  	 Fatigues easily
Frequent upper respiratory infections
Other (describe):  	

Assistive Technology Currently Used   (Check all that apply) Computer, platform:                    Windows                        Mac Computer with screen enlargement                     Writing aids
Computer with Braille output                                Computer with voice output
Low tech access devices (switches)                    Environmental control unit
Low tech vision aids                                             Amplification system/assistive listening device
Low tech communication devices                         Augmentative communication device with voice output
Manual communication board                              Power wheelchair
Manual wheelchair
Other:  	

Additional Valuable Information
1. Describe the assistive technology or alternative & augmentative communication that has been previously tried, the length of time you tried each, and the outcome (how it did/did not work):
Assistive Technology             Length of Trial                        Outcome

2. Are there any behaviors (both positive and negative) that significantly impact the student’s performance?

3. Has the student had a previous AAC or AT assessment? If so, when?

4. Is the student currently receiving speech services? If so, what is the level of service?

5. Are there any other significant factors about the student the team should consider?

Signatures
Name                                            Position                                                    Date
                                                            Parent 	
                                                            LEA Representative  	
                                                            Special Ed Teacher  	
                                                            Regular Ed Teacher  	

Please send this completed form (an incomplete form will be returned), the DEC 2, DEC 7, and relevant psychological and/or educational test results (a DEC 3 Summary may be sufficient) to the Bonnie Emery @ Mary Frances Wall Center.

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