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952-838-9000

Champions for Children with Disabilities

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Consultation Application

A $50 refundable deposit is required with your application to schedule an appointment.

Items marked with an asterisk (*) are required.

Individual information

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Home    Cell

Gender:

    

Have you attended a
consultation in the past?

    

Please list persons who will also attend the consultation (teacher, PCA, therapist or family members).

First Person

Home    Work

Second person

Home    Work


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.

    

  

So we can provide useful information, please completely answer all of the questions that follow.

Purpose of Consultation


Please check all areas that you would like to explore during the consultation:



Technology

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 OS Version:

| Mac OS version:

Is the computer currently used at:          



Background Information




Does the individual have a vision impairment?     

Does the individual wear glasses?     

Does the individual have a hearing impairment?     

Does the individual wear hearing aids?     






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.

Visit PACER's other sites: Teens Against Bullying | Kids Against Bullying | FAST Family Support | MN SEACs

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