Apply for a Device

As a non-profit organization, our mission is to provide long term communication access to individuals in need of all ages and ability levels. Talk with Me Tennessee organizes and allocates the funds necessary to purchase and distribute lite technology communication devices to individuals who have been diagnosed with severe communication impairments.

To be eligible to receive communication equipment from this organization, the client will need an evaluation and/or a letter of medical necessity recommending use of low technology AAC device(s) by a certified Speech Language Pathologist or Assistive Technology Team. Please supply this information in the application below. The application will then be reviewed by a committee at Talk with Me Tennessee. Once the application is approved the client will either receive the equipment immediately, or his/her name will be placed on a waitlist for direct purchase of the recommended devices. Any future repair or replacement of parts such as batteries, wheels, etc. is the sole responsibility of the recipient and Talk with Me Tennessee will make no recommendations for such services.

Apply for a device by clicking the 'APPLY NOW' button below. Fill out the application & click 'SUBMIT'.

Or you can download the Application . Print & fill it out. Make sure to attach the appropriate documents then mail it to us.

Apply For A Device

Section 1

Client Information.

Client Name: *

Client Name:

First Name

Last Name

Client Phone

(###)

###

####

Client Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Email Address *

Language and/or Developmental Diagnosis: *

Section 2

Caregiver Information.

Caregiver Name:

First Name

Last Name

Caregiver Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Caregiver Email:

Caregiver Relationship to Client:

Section 3

Refering Provider Information.

Refering Provider Name:

First Name

Last Name

Refering Provider Credentials

Refering Provider Phone Number

(###)

###

####

Refering Provider Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Section 4

Clients Needs Analysis:

Why you were referred to Talk with Me Tennessee:

How did you find out about Talk with Me Tennessee:

Please briefly explain the client’s communication needs:

Please briefly explain any AAC devices that the client is currently using or has used in the past:

Section 4

Device Request Information:

Name & Price of Device(s) Requested:

Company Name / Device Name / Price of Device

Number of Devices Requested:

Section 4.1

Accessories

Wheelchair Accessories:

Wheelchair Mount

Wheelchair Device Case

Name & Price of Accessorie(s) Requested:

Company Name / Accessory Name / Price of Accessory

Number of Accessories Requested:

Total of Mounts & Accessories Requested

Preferred Method of Delivery

___ to therapist/requesting professional ___ to applicants home ___ applicant will pick up device