Initial Referral for AAC/AT Assessment

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  1. Complete The Following for the Person Requesting The Assessment (District Staff ONLY may be Requester)
    Requestor Name   Requestor Phone  
    Requestor Email

  2. Contact Info for Point Person (This Individual Will be Responsible for Filling out Information Packet)
    Check if Same as Requestor
    Point Person Name  Point Person Phone 
    Point Person Email

    County   School District

  3. Complete this Section for the Student who will Receive the Assessment
    Student's Name 
    Age (years)   Date of Birth  Student Sex   
    Student Ethnicity 


    Current School Attending 
    School Address
    City State ZipCode School Phone Number

  4. State the Reason for Referral and the Goal of Assessment
    Referral Reason  
    Assessment Goal

  5. Release of Information / Disclaimer.