Assistive Technology Solutions Assessment
Please complete this form to help us understand your needs and recommend suitable assistive technology solutions.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
Email
Phone
Text Message
Other
Please select the primary area(s) where assistive technology support is needed.
*
Communication
Mobility
Vision
Hearing
Learning/Cognition
Daily Living
Other
Please indicate the environments where assistive technology is needed.
*
Home
School
Workplace
Community
Other
Please describe your current disability, challenge, or condition (optional).
Do you currently use any assistive technology devices or solutions?
*
Yes
No
If yes, please list the assistive technology devices or solutions you currently use.
Please rate your satisfaction with your current assistive technology solutions.
1
2
3
4
5
What are your primary goals or needs for assistive technology? (e.g., increased independence, improved communication, better mobility)
*
Please indicate your preferences for assistive technology solutions (e.g., portability, ease of use, compatibility with other devices).
Is there any other information or specific request you would like us to consider?
Signature (Please sign below to confirm your consent and the accuracy of the information provided.)
*
Submit Assessment
Submit Assessment
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