Refer someone to Full Circle Assistive Technology

Request assistive technology assessment, training, demonstrations, or recommendations for devices, apps, and software.

Use this form to refer yourself or someone else. First, tell us who you are. Then we'll show only the questions you need to answer. Fields marked with an asterisk (asterisk) are required.

Need help with this form, or unsure which choice fits? Call 7122507201 or email amena.thomas@fullcircleat.com and a person will help you. After you send the referral, we will tell you the date we will contact you by.

I am referring as a…

Vocational Rehabilitation (VR) counselor

I am referring myself

School staff / Teacher of the Visually Impaired

Medical provider (eye doctor, occupational therapist, clinic)

Family member or caregiver

Community agency or program

Employer / other

About you

Your name

How can we reach you? Your phone or your email (at least one).

Your phone

You may text me at this number about my appointments (reply STOP at any time)

Your email

Agency / school / practice / organization Required for counselor, school, medical, and agency referrals.

Your relationship to the person e.g., daughter, spouse, friend — required for family referrals

What help is needed?

Referral purpose New referral: someone new to us. Additional service: an existing client needs another service. Plan amendment: change services already planned (for example, more hours).

Assistive technology services requested Assistive technology means devices, apps and software that help a person with a disability do everyday tasks, such as screen readers, magnifiers and braille displays. Select every service you are asking for. Assessment (we meet the person to find out which tools could help) Assistive technology training (we teach the person to use a device or app) Demonstration (we show devices so the person can try them) Recommendation (we write down which tools to get)

Specific needs (optional) Select all that apply, even if they span more than one service. You may leave these blank if you are not sure. Describe any other needs below. Screen readers Magnification Braille devices Assistive technology for daily living Low vision devices Workplace assessment Device trial / loan Device setup Device repair / technical support Device funding assistance Other assistive technology needs

Do you have an open case with a vocational rehabilitation (VR) agency?

Yes

Not sure

Monthly income

Your monthly income, including benefits. If you are under 18, give your parents' income instead. This only decides whether training is free. We will confirm with you; nothing is charged now.

Below $2,000 per month — free

$2,000 per month or more — $17.50 per hour

Their state

About the person you're referring

Their full name

Date of birth

Their phone

Their email

Their address

Grade level

Parent / guardian name

Parent / guardian phone

What does this person need help with? Tell us which tasks they want technology to help with, the devices or software they use, and any accessibility barriers.

Contact and consent

Who should we contact first?

The person themselves Me first

The person (or their guardian) knows about this referral and agrees to be contacted.

Low-vision controls

Refer someone to Full Circle Assistive Technology

I am referring as a… *