Assistive Technology Coaching Questionnaire (ATQ)

Assistive Technology Coaching Questionnaire (ATQ)
Hello! Thank you for choosing the Possibilities Clinic for Coaching Services. We would be honoured to support you by booking the appointments you need. Before we do that, we require your acknowledgement of the following details around privacy, confidentiality, and insurance coverage. Once you click yes, you are on your way to sharing your concerns and getting an appointment booked with our exceptional coaches!
- Our online forms use SSL encryption to maintain secure transmission of medical information. Forms must be submitted online. This document will be added to your chart in our electronic medical record system and cannot be deleted. Our electronic medical record system is mandated by the Ontario government, professional regulatory organizations, and privacy laws.
- Complete this form if you are interested in receiving Assistive Technology Academic Services. If you wish to receive Assessment and Diagnostic Services from our multi-expert team please complete our standard Clinic Intake Form for children and teens or adults instead.
- Private therapists and coaches from various disciplines are available at Possibilities including Psychologists, Registered Psychotherapists, Social Workers, Occupational Therapists, Speech and Language Pathologists, Nurses, and Teachers. Rates range from approximately $145 to $290 per session. Services from these providers are not covered by OHIP. Fees may be covered by private insurance plans. Please check with your insurer for potential coverage.
- Most services are delivered over secure video sessions.
- Yes, I understand that the Possibilities Team can only respond and book an appointment for me after I have filled out and submitted this intake form.
*

Yes. I understand and agree with the above statements. Please help me book my appointment at the clinicNo. I do not wish to proceed with Possibilities at this time.
Signature (please use mouse or trackpad to sign below)*

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Patient Information
Patient's Full Legal Name*

First NameLast Name
Patient's Date of Birth*

YearMonthDay
Phone Number of Point of Contact *

Area CodePhone Number
Email of Point of Contact*
example@example.com

Education
Current School Board:*
Current School:*
Current Grade:*

	Please indicate your child's areas of strength and need for each of the following items.
Keyboarding
Use of text-to-speech/speech-to-text
Use of audiobooks
Organizing folders and documents
Creating documents (Presentations, documents, spreadsheets)
Sharing documents
Using digital calendar
Internet Research skills (searching, compiling information, summarizing, validity of the information you find)
Accessing email accounts and sending emails (cc, bcc..)
Adding attachments (via email)
Controlling the number of tabs that are open

Thank you for taking the time to complete this form. Please follow the following next steps:

1. After clicking on the Review Button below, you will see a Print/Save button.

2. Please print or save a copy of this document.

3. Once printed or saved, you must then Submit your form.

4. If you have any technical issues, please call our office at 833-482-5558.

We look forward to supporting you through your important next steps. Our Care Team will contact you shortly to share details about your appointment options.

Possibilities Clinic Team

Thank you for taking the time to begin our Intake form.

You have decided not to proceed with Possibilities at this time.

We wish you all the bet on your journey
Should be Empty:

	Name of Assistive Technology	Use at home/school or both	Used in the Past or Currently	Helpful (Yes or No)
1
2
3
4

	Rarely	Sometimes	Always
Can Listen to a 20 minute lesson without getting distracted.
Distinguishes between important and unimportant information/tasks
Completes daily routines (with limited redirection and reminders)
Understands instructions given the first time
Understands instructions with more than two steps.

	Rarely	Sometimes	Always
Knows the alphabet letter names and sounds
Skip/omit words when reading
Sounds out unfamiliar or tricky words
Guess at words when reading
Identifies punctuation when reading. (period, quotation marks, question marks.)
Can Retell/summarize a story.
Can sequence events in a story in the correct order.
Read Fluently - not choppy or robotic
Tracking - Can keep track of the word or line they are reading on a page
Reads books appropriate for their age/grade
Comprehension - Understands what they read when reading independently

	Rarely	Sometimes	Always
Spelling
Hand writing (neatness, orientation and size of letters)
Spacing between words
Use of Punctuation (? ! “ . ,)
Complete sentences
Planning prior to writing
Generating ideas for writing
Sequencing ideas in their writing
Paragraph writing
Proofreading/Editing

	Rarely	Sometimes	Always
Time management (Knowing how long something may take and managing time accordingly)
Planning and Prioritizing (homework, assignments, studying)
Organization (schedules, space)
Task completion (able to complete a task from start to finish)
Goal setting (Looking ahead and identifying things they would like to achieve/.accomplish.)
Self-regulation (controlling thoughts, feelings and behavior
Focus (too much or too little)
Working Memory (keeping important information in mind)

Assistive Technology Coaching Questionnaire (ATQ)

Patient Information

Education

Current Computer Access and Use

Skills Assessment

	Home	Work
1
2
3
4