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Illinois Assistive Technology Program

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Initial Referral for AAC/AT Evaluation

Complete The Following for the Person Requesting The Evaluation (District Staff ONLY may be Requestor)

   
   
   
   
   
 
 

Contact Info for Point Person (This Individual Will be Responsible for Filling out Information Packet)

 
 
 
 
 
 
 
 
 
 

Complete this Section for the Student who will Receive the Evaluation

   
   
   
 
 
 
 
   

School

List of schools below changes based on the District selected for Contact Info.

   
   
   
   
   
   
   

State the Reason for Referral and the Goal of Evaluation

Evaluation Type

Evaluation Type (Required):

Release of Information / Disclaimer



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