AT Referral Form Assistive Technology Referral Form Step 1 of 5 20% Individual InformationFirst Name*Last Name*MiddleDate of Birth (mm/dd/yyyy)* MM DD YYYY AgeDiagnosis*Home Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Work Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Work PhoneCell PhoneEmail Referral InformationName of Person Making Referral (If Making Referral on Behalf of Individual)Relationship to IndividualAddress (If Different From Individual) Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneEmail Please describe the reason for Assistive Technology Referral?*If you are seeking AT configuration or training for a particular device, please include it here.Please describe any current or previous use of Assistive Technology?* Availability for AssessmentWeekdays:*Check all that apply. Monday Tuesday Wednesday Thursday Friday Time of Day:*Check all that apply. Morning Afternoon Desired Appointment Location:*7215 York Rd., Baltimore, MD 21212Is the individual currently served in The Arc Baltimore's programs?*YesNo Billing InformationASSISTIVE TECHNOLOGY FEES: Assistive Technology Assessment - $250 Assistive Technology Configuration and Training - $75 / hour Travel fees for any service outside of The Arc Baltimore - $20 / hour Please indicate where to send the invoice:*IndividualPerson making referralSend invoice via:*EmailMail Individual SignatureSignature*Date* Guardian's Signature (If Applicable)Date