Simon Technology Center Adult Consultation Form

PACER Center
952-838-9000

Champions for Children with Disabilities

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Adult Consultation Information

A $50 refundable deposit (a check made out to PACER) is required with your application to schedule an appointment.

Items marked with an asterisk (*) are required.

* Name:

Date of Birth:

* Address:

* City, State and Zip:

* Phone: (home) (work)

E-Mail:

* Disability:

We recommend you bring any professionals working with you (such as a therapist, OT, PT, teacher, PCA) to the consultation.

Please list professionals who will be attending the consultation.

Name:

Address:

City, State and Zip:

Phone: (home) (work)

Relationship:

Name:

Address:

City, State and Zip:

Phone: (home) (work)

Relationship:

So we can provide useful information, please completely answer all of the questions that follow.

Photo Release Permission (Optional)

I will allow PACER Center to use any picture or videotape taken that might include me. Pictures are used for general publicity purposes; newsletters, brochures, photos to accompany articles sent to other publications, videotape, or computer presentation.

Yes No

Name: Date:

Consultation Information

What would you like to accomplish at your consultation with Simon Technology Center?

How do you think that computer technology can help you at school, work, or at home?

Do you own a computer? If so, what type, what operating system, does it have a CD-ROM?

What type of computer, software and assistive technology (i.e. trackball, switch, touch screen, etc.) do you use at school, work, or home?

What is your history of assistive technology use?

Do you use any communication aids? Please describe.

Do you experience seizures of any kind? If so, do you have any reason to believe computer use may be a factor?

Do you have any vision or hearing problems? Please describe.

What are your gross and fine motor skills? Please describe.

Estimate your cognitive and communication range and abilities in the following catagories:
(estimate in years, if possible).

Cause and effect
Language comprehension
Expressive language / speaking ability

Describe skills you are learning at the present time.

What are your interests, dislikes and motivators?

Please share any other information that might be relevant to the consultation.

You will have the option to print this form after you click submit.

Thank you for taking the time to fill out this consultation form.
It will help in making the most of your consultation at PACER.

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Simon Technology Center

Adult Consultation Information

Photo Release Permission (Optional)

Consultation Information