Smart Living Assistive Enabling Technology Referral Form

Smart Living Assistive Enabling Technology Referral Form
Individual Demographic Information

Please enter information regarding the individual being referred.
Individual Name

First NameLast Name
Individual's Date of Birth

MonthDayYear
Individual's Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Individual's Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Individual's Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Individual's Email Address
example@example.com
Referrer Information

Please provide information for the person completing this referral.
Are you completing this referral for yourself?
Referrer Name

First NameLast Name
Referrer Agency
Referrer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referrer Email
example@example.com
Individual's Supports Information

Please enter information regarding the individual's supports.
Supports Coordinator / OVR Counselor Name

First NameLast Name
Supports Coordinator / OVR Counselor Email
example@example.com
Supports Coordinator / OVR Counselor Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship to Individual
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Family / Caregiver / Support Provider Name

First NameLast Name
Family / Caregiver / Support Provider Phone
Please enter a valid phone number.Format: (000) 000-0000.
Family / Caregiver / Support Provider Email
example@example.com
Individual's Current Status / Assessment Information
Current Technology utilized by the individual:
Individual's strengths, skills and interests:
Purpose / Goal of this referral (Please describe any barriers / challenges / needs):

Please provide information regarding the individual's disabilities or diagnoses:

Rows	Disability / Diagnosis
1
2
3
4

Please provide any information regarding indvidual's accommodations or accessibility requests:
Evaluation Requested
Please select the evaluation being requested:

Assistive Technology Assessment for Independent Living:
This may include support for smart home devices, environmental controls, medication/appointment reminders, memory, literacy, organization and executive functioning, physical accessibility, support with daily activities(cooking/cleaning/eating/dressing, etc.) behavioral support, safety/security in home/community, functional skills support, home modifications and medical equipment.
.Assistive Technology Assessment for Higher Ed. Transition, Pre-Vocational:
This may include support for access to digital accessible educational materials (alternative format for books and handouts), reading & writing support, executive function (organization, time management, study skills, focus and attention, self-regulation), sensory support (magnification, screen reader, captioning options, sound amplification), hardware or software for a specific need, physical access support, communication, etc.
. Assistive Technology Assessment for the Workplace:
This may include computer access (trackball, joystick, adapted keyboard, touchscreen, tablet, eye gaze, head control, on screen keyboard), accessible workstation, ergonomic support, switch access, workplace accessibility, accessible meeting materials digital accessible handouts/communications, literacy support, sensory support (vision/hearing), physical access needs, executive functioning, etc.
Document Upload
Please upload any relevant documents or reports that are available These could include an ISP or Medical, OT, PT, Speech, Vision, Hearing, Learning, FBA reports.

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Smart Living Assistive Enabling Technology Referral Form

Individual Demographic Information

Referrer Information

Individual's Supports Information

Individual's Current Status / Assessment Information

Evaluation Requested

Document Upload