Physical Therapy Request For Service
Certified teachers (general and special education) can request PT support or consultation for a student. Please complete this form in order to receive timely and meaningful services.
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Student Name(First and Last) *
Grade Level of Student *
Attendance Center( Where does the student attend school?) *
Is student new to the district *
Does Student have an IEP? *
Type of service requested *
If requesting Evaluation do you have a doctors script? *
Describe the Physical/Gross motor Concerns *
What is the educational impact of your concern or what is the physical barrier to the students education?( ie. where and when is this causing problems)
Name and email address of person to schedule screening or evaluation with? *
Name of person completing this form *
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