Assistive Technology intake form

Please complete this form if you are interested in seeking Assistive Technology / Augmentative and Alternative Communication (AAC) to help your child with speech, language and social communication.

Patient's Name
Patient's Date of Birth
Name of Person Filling Out This Form
Email(Required)

Tell Us About Your Child

Does your child consistently:(Required)
Check all that apply.
Has your child used a form of assistive technology in the past?(Required)

Fine Motor/Gross Motor/Sensory Skills

Does your child have a hearing or vision impairment?(Required)
Does your child have functional use of one or more finger?(Required)
Does your child have the ability to reach out and touch objects or screens?(Required)

Past/Present Therapy

Is your child currently receiving speech therapy?(Required)
Has your child received formal speech/language therapy in the past?(Required)
Has your child received formal occupational therapy in the past?(Required)
Has your child received formal physical therapy in the past?(Required)
Is your child currently enrolled in ABA therapy services?(Required)
Consent(Required)