M.G.S.D. Assistive Technology Consultation Request Form    
                                                       

The following questions will be used as a guide for organizing the in-district Assistive Technology Consultant Team.  By providing specific information, team members will be chosen to best fit the student’s area of need(s).

Student’s name: _______________ Birth date: ________________

Today’s date: __________  School: _________________________

Grade: ______  Classroom teacher: _________________________

Person completing this guide: ___________________________  

phone number______________ext. _____  

What goals are you hoping to achieve for this student? ___________________________________________________________________________
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Student’s Disability (check all that apply) Name of Resource Staff

• Speech / Language           _____________________

• Occupational Therapy      _____________________

•   Physical Therapy             _____________________

•   Special Education            _____________________

•   Other                             _____________________

Comments:__________________________________________________________________
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