Assistive Technology Referral Form - Sonoma County SELPA

Sonoma County SELPAAdaptive Technology CenterLa Fiesta Education Center, 8511 Liman Way, Rohnert Park, CA 94928Phone: (707) 829-9526 Fax: (707) 792-45883 of 6Vision:Hearing:Fine Motor:Cognitive Skills:Academic Skills: ReadingAbilities:Challenges: WritingAbilities:Challenges:For ATC Use:Date Request Rec’d:Reviewed by:

Sonoma County SELPAAdaptive Technology CenterLa Fiesta Education Center, 8511 Liman Way, Rohnert Park, CA 94928Phone: (707) 829-9526 Fax: (707) 792-45884 of 6 SpellingAbilities:Challenges: MathAbilities:Challenges:Current Computer/Technology Skills and Equipment:Communication SkillsExpressiveReceptiveSocial/Behavioral Skills: positive and negativeFor ATC Use:Date Request Rec’d:Reviewed by:

Sonoma County SELPAAdaptive Technology CenterLa Fiesta Education Center, 8511 Liman Way, Rohnert Park, CA 94928Phone: (707) 829-9526 Fax: (707) 792-45885 of 6Student’s strengths, learning style, coping strategies, or interests:Other Issues, Comments, Information that the team should consider:Does student fatigue easily, or experience a change in performance at different times ofthe day? the day?Thank You!For ATC Use:Date Request Rec’d:Reviewed by:

Sonoma County SELPAAdaptive Technology CenterLa Fiesta Education Center, 8511 Liman Way, Rohnert Park, CA 94928Phone: (707) 829-9526 Fax: (707) 792-45886 of 6Follow-Up Action:Consultation Referrals FOR LI STUDENTS: Phone Call to referring party Date:___________ Review of IEPDate: __________ Observation of mainstream setting and classroomDate(s): ___________RECOMMENDATIONS:Based upon information received and further exploration, including steps outlined below, thereferred student’s strengths appear to be:1.2.3.Areas of need include:1.2.3.Suggested interventions include:1.2.3.REFERRALS WITH SIGNED ASSESSMENT PLANS FOR STUDENTS WITH A LOW INCIDENCEDISABILITY: Observation of referred student:Date(s): ________________ Meeting with referred student and/or teacher: Date: _____________ Assessment Report will be submitted to the IEP team within 60 days ofthe signed Consent for Assessment Plan. Consultation with equipment with student and/or classroom staff:Date: ______ Training period with LOANER equipment: ____________________________For NON Low Incidence Eligible Students:If there is a signed assessment plan in place for a student with a NON LI DISABILITY, please contact PiaBanerjea, at (707) 524-2758 or pbanerjea@sonomaselpa.org before submitting referral to ATC.If there is no signed assessment plan in place, follow-up actions will include: Phone call/consultation Trainings for staff Workshops. Please note, workshops will be scheduled per request from districtadministrators. Please see the SELPA website for a workshop menu.Submitted by: _________________________(Printed Name)For ATC Use:Signature of AT Specialist: ___________________________Date Request Rec’d:Date of report: ________________Reviewed by: