A $50 refundable deposit is required with your application to schedule an appointment.
Items marked with an asterisk (*) are required.
Parent/Guardian name(s) (if applicable):
Relationship to individual (if applicable):
* City, State and Zip:
Date of Birth:
Grade (if applicable):
Have you attended a consultation in the past?
Best means to contact(phone, email):
Please list persons who will also attend the consultation (teacher, PCA, therapist or family members).
City, State and Zip:
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.
So we can provide useful information, please completely answer all of the questions that follow.
What would you like to accomplish during the consultation with the Simon Technology Center?
Please check all areas that you would like to explore during the consultation:
Are any of the following assistive technologies currently being used at home, school or work?
If you own a computer, what kind of operating system does it have?
Windows | Windows OS Version:
Mac | Mac OS version:
Is the computer currently used at:
Describe the individual’s current skills in reading, writing and mathematics.
Please describe gross motor skills (large muscles for sitting, standing).
Please describe fine motor skills (small muscles for eating, writing).
Does the individual have a vision impairment?
No Please describe:
Does the individual wear glasses?
Does the individual have a hearing impairment?
No Please describe:
Does the individual wear hearing aids?
Describe skills the individual is currently learning.
Describe strengths, learning styles, interests, motivators, and dislikes that may help us in planning for the appointment.
Should we be aware of any environmental allergies (latex, cleaning products, etc.)
that may be encountered during the appointment?
Would low-lighting or sensory tools (beanbag chair, sensory balls, breaks, etc.) be beneficial during the consultation?
Please share any additional information that might be relevant as we plan for 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.