Technical Assistance Form
Office Use Only:
Date Received:
______________
Instructions:
Please check and update all information for accuracy.
Once you fill out all fields, we recommend that you print a hard copy.
Name:
(first, middle initial, surname)
Agency:
Male
Female
Address:
Daytime Phone #:
Name of Child in Need of Assistance:
Date of Birth: (mth/day/yr)
Male
Female
Address:
Your relationship to child:
What Type of Technical Assistance Interests Might Fill Your Needs?
In-service
Phone Contact
Home Visit
Other
(specify)
School Visit
What Topics Would You Like Addressed?
Auditory Training / Listening Skills
Orientation and Mobility Skills (travel independence)
Assessment Information and/or Referral (
if form is printed and mailed, please circle area: vision, hearing, communication, development or other)
Organizing a Daily Routine (sequence of activities, transition from one activity to another)
Behavior Management/Social Emotional Concerns (relationship with others)
Parent to Parent Contact
Communication System Development
Recreation and Leisure Skills
Daily Living Skills (personal care and self-help skills such as toileting, dressing, etc.)
Resources: Information and/or Referral
Home or Classroom Observation/Recommendations
Sensory Skill Development (vision, hearing, tactile skill use)
Inclusion into School Program (techniques that support the child’s learning in the regular classroom)
Transition (early childhood to school or school to adult services)
Literacy Mode Determination (use of braille, large print, etc.)
Vocational Training
Medical Issues (gaining more information about a child’s diagnosis)
Other
(specify)
Remember to Print a Copy!