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Full Individual Evaluation Request
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Introduction
Referral
*
Choose
Self
School
Physician
Agency
Other
Your Name
*
Your answer
Child's Name
*
Your answer
Age(s) of other siblings
*
Your answer
Work Phone Number
*
Your answer
Cell Phone Number
*
Your answer
Email Address
*
Your answer
Best day(s) and time(s) to reach you
*
Your answer
Communication Preference
*
Work Phone
Cell Phone
Email
Text
Required
Medical History
Is your child on medication? If so, please list and include dosages.
*
Your answer
Vision Testing?
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Your answer
Hearing Testing?
*
Your answer
Education History
What is the biggest challenge facing your child today?
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Your answer
How many schools has your child attended throughout his/her education?
*
0
1
2
3
4
5
6
What is your child's program? (check all that apply)
*
504 Accommodations
Special Education
Bilingual Education
Gifted and Talented
English as a Second Language
Other:
Required
Do you have copies of these records? (check all that apply)
*
Report Cards
Immunization Records
Special Education
504
LPAC
Student Work Samples
Writing Sample
Evaluations
School Discipline/Teacher Referrals
Teacher Notes
Information from organizations/agencies (Girl Scouts, Little League Football, Court, etc.)
Other:
Required
Current School Information
Name of School
*
Your answer
Type of School
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Traditional Public
Public Charter
Private
Home School
Other
School Counselor's Name
*
Your answer
Names and roles of all your child's teachers, including social workers, speech/language therapists, occupation therapists, etc.
*
Your answer
Grade Level
*
Choose
PK3
PK4
Kinder
1
2
3
4
5
6
7
8
9
10
11
12
Post-secondary
Graduate School
Age
*
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Strongest academic areas
Your answer
Academic ares of concern
Your answer
When did the school develop your child's first IEP?
Your answer
When did the school develop your child's first 504 Plan?
Your answer
What are your child's disabilities, according to the school?
Your answer
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