Adult Client Intake Form
For adults seeking assistive technology services for themselves. It asks about your goals, the tasks you want to do, and your access needs.
Download the Adult Client Intake Form (PDF)Forms
Find the intake and release forms for our Assistive Technology services. Choose the one that fits your situation, complete it, and send it back to us.
Before your first appointment, we ask for a short intake form so we can understand your goals and needs ahead of time. Pick the form that describes your situation, fill it out, and return it to us. If any form is hard to complete on your own, contact us and we will help you finish it by phone, and we can provide any form in a different accessible format on request.
Available forms
Parent Intake Form
For a parent or guardian requesting services on behalf of a child. It gathers background about your child and the support you are looking for.
Download the Parent Intake Form (PDF)School Intake Form
For schools and districts requesting an assessment or services for a student. It collects the details our team needs to prepare.
Download the School Intake Form (PDF)Information & Media Release Form
Gives us your permission to share information or media where needed for your services. Include it with your intake form when it applies.
Download the Information & Media Release Form (PDF)How to submit your form
Return your completed form whichever way is easiest for you:
- By email: send it to at-services@c4at.org
- By mail: print it and mail it to Center for Accessible Technology, 3075 Adeline Street, Suite 220, Berkeley, CA 94703
Prefer not to use the PDF? Call us at (510) 841-3224 and we can complete the intake with you over the phone, or send the form in a different accessible format.