← AssistiveTechnologyEvaluations.org

Request an Assistive Technology Evaluation

Use this form to request information about an assistive technology evaluation or assessment. Please provide only the information needed for initial contact. Detailed medical, educational, or disability documentation is not required through this form. Submission of this form does not establish a professional relationship or guarantee eligibility, funding, or services.

Fields marked “required” must be completed.

Your Role (required)
Primary Setting (required)
Type of Evaluation or Support Requested (optional) These choices are for routing and general understanding only. Selection does not imply that every listed service is currently available in every location or circumstance.
Please briefly describe the access concern or reason for requesting information. Do not include detailed medical records, diagnoses, Social Security numbers, insurance numbers, or other sensitive information.
City and State (please do not include a street address)
Preferred Contact Method (required)
How Did You Hear About Us? (optional)
Security check (required) This confirms you are a person rather than an automated system. It usually completes on its own.

Important Information Before You Submit

Please do not submit confidential medical records, detailed diagnostic documentation, Social Security numbers, financial account information, or other highly sensitive information through this initial inquiry form. Information submitted will be used to respond to your request and should be handled in accordance with the Accessibility Clinic Privacy Policy.

Submitting this form does not create a professional-client relationship, guarantee an evaluation, establish eligibility for services, or guarantee payment or reimbursement by a school, insurer, government program, or other funding source.