Skip to content
Email
509.963.3350
Cart
0
Home |
Technical Assistance
| Professional Development
Webinars
Classes/Conferences
Awe and Wonder Podcast
WA State AT Meetings
Training Request
Book Studies
SETC Pricing
| Lending Library
Lending Library
Lending Catalog
Software Catalog
| About Us
| Help
| OSPI/IPTN
| Login
Make a Payment
Register
Search for...
Navigation Menu
Navigation Menu
Search for...
Home |
Technical Assistance
| Professional Development
Webinars
Classes/Conferences
Awe and Wonder Podcast
WA State AT Meetings
Training Request
Book Studies
SETC Pricing
| Lending Library
Lending Library
Lending Catalog
Software Catalog
| About Us
| Help
| OSPI/IPTN
| Login
Make a Payment
Register
Paid Technical Assistance Request
Form Submission is restricted
Form is successfully submitted. Thank you!
Paid technical assistance request
Student Information
If you have documents to share with SETC, please upload them here:
Upload
% Completed
0
Student's Name
Student's Birthdate
ESD
Other
ESD 101 Spokane
ESD 105 Yakima
ESD 112 Vancouver
ESD 113 Olympia
ESD 114 Bremerton
ESD 121 Tacoma/Seattle
ESD 123 Kennewick
ESD 171 Wenatchee
ESD 189 Anacortes
ESD Other
School District
School Student Attends
First Name of Primary Contact
Last Name of Primary Contact
Email of Primary Contact
Phone of Primary Contact
Consultation Goal. What are you hoping to gain from this consultation?
What tasks are difficult for your student for which
Assistive Technology
might help?
Student Grade
Eligibility Category - according to IDEA
Autism
Deaf-blindness
Deafness
Emotional/Behavioral disability
Hearing impairment
Intellectual Disability
Orthopedically impaired
Moderate Intellectual Disability
Specific Learning Disability
Speech or Language Impairment
Traumatic Brain Injury
Other Health Impairment
Multiple Disabilities
Other
N/A
American Indian or Alaska Native
Black or African American
Hispanic/Latino
Native Hawaiian or Other Pacific Islander
Two or more races
White
What is the students Ethnicity?
Other
Student's diagnosis (e.g. Muscular Dystrophy, Cortical Visual Impairment, etc.)
What are the student's interests? (think about home, school, and community)
Is your district's AT team/contact involved with this student/team? Please describe and add their email below.
Sensory & Cognition
Vision- Does the student appear to have typical vision?
Yes
No
Other
Other
If "no" please list vision assessment date and results and/or describe the student's vision:
Description
Hearing- Does the student appear to have typical hearing?
Yes
No
Other
Other
If "no" please list hearing assessment date and results and/or describe the student's hearing:
Describe the student's intellectual functioning such as: sequencing, memory and recall, generalizing skills, etc.
IEP Goal Areas
The student has IEP goals in the following areas:
Reading
Writing
Math
Cognitive
Communication
Fine/Gross Motor
Adaptive
Behavior
Other
Other
Reading
Reading- Describe decoding AND comprehension levels (e.g. percentile, grade level, etc.):
Briefly describe the student's reading goals:
Writing
Describe the student's writing skills
Grade level, including how the student most effectively expresses himself/herself from pre-writing to editing/proofreading:
Spelling
student spelling is within expected limits
student spelling is below expected limits
Other
Other
Briefly describe the student's writing goals:
Math
Describe the student's math skills (grade level) and what pre-math skills the student has mastered:
How does he/she demonstrate understanding of math concepts?
Specify use of paper/pencil, manipulatives, calculator, oral response, etc.
Briefly describe the student's math goals:
Communication
Describe, in general, how the student currently communicates. Please include meaningful behaviors in your description.
Briefly describe the student's communication goals:
Receptive Skills
Receptive and expressive skills appear commensurate
Receptive skills are lower than expressive skills
Receptive language has been formally assessed (please list results in other)
Other
Other
Augmentative Alternative Communication (AAC)
Has the student used/trialed any AAC systems? Please list systems and relative information e.g. LAMP on iPad trialed in preschool.
Motor
Describe student’s physical movement, positioning, dexterity, range, strength, dependability (in layman’s terms).
Include smallest area student can accurately point and widest range of access.
Hand preference:
Right
Left
Both
Unknown
Briefly describe student's motor goals:
How did you hear about SETC?
Email
School/Coworker
Parent
Conference
OSPI
Facebook
Other
When considering AT in the IEP, what process does your district use?
District created process/form
SETT
QIAT
WATI
No process in place
Other
Other
Submit