Referral Process/forms

For a new referral for an assistive technology evaluation, please discuss this plan with the IEP team, including parents, to make sure that this is the direction you would like to take and determine what you would like to accomplish with technology. The consent to evaluate form is in Synergy, requiring a parent signature. The other two forms are here: the AT request form and the Parent Survey. The parent survey is very helpful for input but not required.

Please get the forms to me at the district office, SSD department, or send them via email and then I will contact the teacher to set up a time to meet with the student.

These are fillable forms.  Type into the blue fields.

Parent Survey

Assistive Technology  Request form

Note: If the parent survey doesn’t come back quickly, I can start the process without it. It’s a nice way to get input from the family in regards to what equipment they have at home, what they’ve tried, what there concerns are, etc…

Questions: contact

Kelley Moriarty at 


Jordan Gentzkow at