Assistive Technology Consultation Request Form

Step 1 of 6: Personal & Contact Information

Section 1: Personal & Contact Information

Please share details about how we can reach you and address you properly.

Full Name (Required)

Enter your full name as it should appear on official correspondence.

Date of Birth (Required)

Select your date, month, and year of birth.

Phone Number (Required)

Provide a valid phone number for callback.

Email Address (Required)

We will send a copy of your response to this address.

Address Line 1

Address Line 2

City (Required)

State (Required)

PIN Code (Required)

Guardian / Caregiver Relation (if applicable)

Select relation if caregiver assistance is needed.

Guardian / Caregiver Name

Enter their full name.

How did you hear about Samarthanam ATA? (Select all that apply)

Friends

Relation

Social Media

Doctor / Medical Professional

NGO / Community Program

Other (please specify):

Step 2 of 6: Disability Information

Section 2: Disability Information

Providing precise disability information helps us tailor specific technology solutions.

Type of Disability (Select all that apply) (Required, select at least one)

Visual Impairment / Blindness

Low Vision

Hearing Impairment / Deafness

Mobility / Locomotor Disability

Speech & Language

Intellectual / Learning Disability

Other (please specify):

Do you have a valid Disability Certificate? (Required)

Yes (You will be able to upload a copy in Section 6)

Brief description of how your disability affects daily life (Required)

This helps us gauge functional limitations and find custom software or device solutions.

Step 4 of 6: Main Problems & Challenges

Section 4: Main Problems & Challenges

This is the most important section to help us identify exact solutions.

Please select the areas where you face challenges (Select all that apply) (Required, select at least one)

Reading or accessing printed/digital content

Using computer or smartphone

Studying or learning

Working or job-related tasks

Mobility or daily living activities

Communication (speaking, hearing, writing)

Other (please specify):

What is the biggest difficulty you are facing right now? Please describe in detail. (Required)

Please be as detailed as possible. Share the exact barrier or task you want to perform.

Tell us more about your problem(s) with examples

Real-world scenarios make it easier for our team to test and find solutions.

Step 6 of 6: Additional Information & Consent

Section 6: Additional Information & Consent

Final details, supporting files, and your declaration signature.

Share supporting documents (Disability certificate, medical reports, setup photos, etc.)

Drag and drop files here, or browse local files

Supports PDF, JPG, PNG, and DOCX (Max size: 5MB per file)

Preferred contact method (Required, select at least one)

Phone Call

In-person visit (if possible)

Any other notes or information

Consent & Declaration

I confirm that the information provided is true to the best of my knowledge.

I consent to Samarthanam ATA contacting me for follow-up, assessment, or support.

Signature / Name and Date (Required)

Draw Signature (Draw inside canvas using mouse, finger or stylus)

Canvas draw area. Draw your digital signature here. Use the clear button below to start over.

Or Type Full Name

Use this if drawing is difficult or if you are using a screen reader.

Date

Automatically selected to today's date.

Assistive Technology Consultation Request Form

Section 1: Personal & Contact Information

Section 2: Disability Information

Section 3: Current Assistive Technology & Situation

Section 4: Main Problems & Challenges

Section 5: What Help Do You Need?

Section 6: Additional Information & Consent

Thank You!