Student/Consumer Information

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* 1. This consultation is for a:

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* 2. Student/Consumer Information

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* 3. Age and/or date of birth for person attending consultation:

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* 4. Grade in school/school name (if applicable):

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* 5. Parent/Guardian/Primary Contact information (required for student under age 18):

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* 6. Secondary Contact information (optional):

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* 7. Preferred means of contact:

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* 8. What best describes the gender for the child/individual receiving the consultation?

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* 9. Please list your/your child's/the consumer's preferred pronouns:

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* 10. Please tell us about your/your child's/the consumer's disability:

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* 11. Primary Language

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* 12. If your primary language is not English, will you require a translator?

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* 13. Have you/your child/the consumer attended a consultation at the PACER Simon Technology Center in the past?

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* 14. PACER welcomes additional support professionals (teacher, PCA, therapist, family member, etc.) whose presence may be beneficial at the consultation.

Please include the full name(s) of any additional individuals who will attend and their relationship to student/consumer.

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* 15. Would you prefer an in-person or virtual consultation?

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33% of survey complete.

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