Simon Technology Center Child Consultation Form

PACER Center
952-838-9000

Champions for Children with Disabilities

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Child 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.

* Parent's Name:

* Address:

* City, State and Zip:

* Phone: (home) (work)

E-Mail:

* Child's Name:

Date of Birth: Grade:

* Disability:

We recommend you bring any professionals working with your child (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 your child at school 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.) does your child presently use at home or at school?

What is your child's history of assistive technology use? (You may need to ask school personnel for this information).

Does your child use any communication aids? Please describe.

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

Does your child have any vision or hearing problems? Please describe.

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

Estimate your child's cognitive and communication range and abilities in the following categories:
(estimate in years, if possible).

Cause and effect
Language comprehension
Expressive language / speaking ability

Describe skills your child is learning at the present time.

What are your child's 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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Child Consultation Information

Photo Release Permission (Optional)

Consultation Information