PACER Simon Technology Center Assistive Technology Consultation Application

Student/Consumer Information

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* 1. This consultation is for a:

Child/Student Under 18

Adult/Consumer

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* 2. Student/Consumer Information

Name (First and Last)

Address

City

State

ZIP/Postal Code

Email Address

Phone Number

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* 3. Age and/or date of birth for person attending consultation:

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* 4. Grade in school/school name (if applicable):

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* 5. Parent/Guardian/Primary Contact information (required for student under age 18):

First and Last Name of Primary Contact

Relationship

Address (if different from above)

City

State

ZIP/Postal Code

Email Address

Phone Number

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* 6. Secondary Contact information (optional):

First and Last Name

Relationship

Address (if different from above)

City

State

ZIP/Postal Code

Email Address

Phone Number

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* 7. Preferred means of contact:

Phone call (please list best days/times to call in the specific directions for consultation communication box below)

Text message (by checking this box, you agree to receive occasional text messages regarding your consultation)

No preference

Specific directions for consultation communication:

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* 8. What best describes the gender for the child/individual receiving the consultation?

Female

Male

Non-Binary

Prefer not to say

Prefer to self-describe:

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* 9. Please list your/your child's/the consumer's preferred pronouns:

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* 10. Please tell us about your/your child's/the consumer's disability:

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* 11. Primary language:

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* 12. If your primary language is not English, will you require a translator?

Yes - I would like PACER to provide a translator.

Yes - I will bring someone who can translate.

No - I do not require a translator.

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* 13. How did you hear about our consultation service?

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* 14. PACER welcomes additional support professionals (teacher, PCA, therapist, family member, etc.) whose presence may be beneficial at the consultation.

Please include the full name(s) of any additional individuals who will attend and their relationship to student/consumer.

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* 15. Would you prefer an in-person or virtual consultation?

We prefer an in-person consultation at the PACER Center.

We prefer to have a virtual consultation via Zoom.

We would like to decide once we speak to our specialist about scheduling.

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PACER Simon Technology Center Assistive Technology Consultation Application

Question Title

* 1. This consultation is for a:

Question Title

* 2. Student/Consumer Information

Question Title

* 3. Age and/or date of birth for person attending consultation:

Question Title

* 4. Grade in school/school name (if applicable):

Question Title

* 5. Parent/Guardian/Primary Contact information (required for student under age 18):

Question Title

* 6. Secondary Contact information (optional):

Question Title

* 7. Preferred means of contact:

Question Title

* 8. What best describes the gender for the child/individual receiving the consultation?

Question Title

* 9. Please list your/your child's/the consumer's preferred pronouns:

Question Title

* 10. Please tell us about your/your child's/the consumer's disability:

Question Title

* 11. Primary language:

Question Title

* 12. If your primary language is not English, will you require a translator?

Question Title

* 13. How did you hear about our consultation service?

Question Title

* 14. PACER welcomes additional support professionals (teacher, PCA, therapist, family member, etc.) whose presence may be beneficial at the consultation.Please include the full name(s) of any additional individuals who will attend and their relationship to student/consumer.

Question Title

* 15. Would you prefer an in-person or virtual consultation?

* 14. PACER welcomes additional support professionals (teacher, PCA, therapist, family member, etc.) whose presence may be beneficial at the consultation.

Please include the full name(s) of any additional individuals who will attend and their relationship to student/consumer.