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Evaluation Request
This form does not guarantee an appointment will be scheduled. We will reach out when we have availability.
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* Indicates required question
Email
*
Your email
Name of child
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
School District
*
Your answer
County
*
Choose
Albany County
Schenectady County
Saratoga County
Rensselaer County
Other
Type of evaluation requested as listed on the district consent form:
*
Psychological Evaluation
Speech Evaluation
Occupational Therapy Evaluation
Physical Therapy Evaluation
Classroom Observation
Social History
Physical/Medical Record Review
Other:
Required
What concerns do you have about your child?
*
Your answer
Where is your child during the day?
*
Home
Daycare
EPK
UPK
Required
If your child is in daycare, EPK or UPK, what town or city is it located in? What is the name of the program?
Your answer
If your child attends a program, what days do they attend?
Monday
Tuesday
Wednesday
Thursday
Friday
Other:
Parent/Guardian Name:
*
Your answer
Parent/Guardian address:
*
Your answer
Parent/Guardian contact phone #:
*
Your answer
Parent/Guardian email:
*
Your answer
What is the primary language spoken in your home?
*
Your answer
Does your child currently receive services? Check all that apply.
*
Speech Therapy
Occupational Therapy
Physical Therapy
Special Instruction
Does not currently receive services
Other:
Required
Who made the referral?
*
Your answer
A copy of your responses will be emailed to the address you provided.
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