Assistive Technologies Intake Form

Name:

Student Number: 

Email address:

Best way to contact the student: 

Is CSG funding available? Yes No Maybe

What will be required? Training Consultation

What is the technology for?

Exams General coursework/studying

Other:

What are the areas of concern?

Reading Writing Attention Studying

Mind-mapping/Brainstormin Other:

Mac or PC:

Previous working knowledge of any of the following?

Dragon Naturally Speaking: Yes No

Kurzweil 3000: Yes No

Read & Write Gold: Yes No

Zoom Text: Yes No

Jaws: Yes No

Window Eyes: Yes No

Inspiration: Yes No

Mind View: Yes No

Other:

Additional Comments (What you are looking to use, previous program experience, concerns...):