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Request for Assistance
First Name
Last Name
School/Agency
Division
City
State
Contact Phone Number
Email
What age level students do you work with?
Preschool
Elementary
Middle
High
Choose one of the following to describe your position
Administrator, General Education
Administrator, Special Education
Behavior Specialist
College Student
School Counselor
Human Services Agency Staff
Mental Health Specialist
Occupational Therapist
Paraprofessional
Parent/Family
Physical Therapist
Pre-K–12 Student
School Counselor
Social Worker
Speech Pathologist
Teacher, General Education
Teacher, Special Education
Transition Coordinator
University Faculty
Voc. Teacher/Admin.
Other
What is your request?
How did you hear about T/TAC Services?
Disability Descriptions (please check all that apply)
ADD/ADHD
Autism
Deaf Blind
Deafness
Developmental Delays
Emotional Disturbance
Hearing Impairment
Learning Disability
Intellectual Disability
Multiple Disabilities
Orthopedic Impairment
Speech/Language Impairment
Traumatic Brain Injury
Visual Impairment
Other Health Impairment
Choose which of the following describe your program affiliation
Adult Education/Family Literacy
Community Based Preschool
Early Childhood Special Education
Early Intervention
Even Start
General Education
Head Start
Homeless
Migrant Education
Occupational Child Care
Preschool Initiative
School Age Special Education
Title 1
Other
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