Evaluation Request Form

EVALUATION REQUEST FORM

Use this form to request a formal educational or related-services evaluation to determine educational needs, eligibility for services, or instructional planning. By submitting this form and signing below, the undersigned authorizes the institution to collect, review, and release educational, medical, and developmental records as necessary to complete the evaluation. The evaluation findings will be used for educational planning and may be shared with the student’s instructional team in accordance with applicable confidentiality requirements.

Student Information

Student Name:    Date of Birth:

Student ID:    Grade / Program:

Phone:    Email:

Referral Information

Date of Referral:

Requested Evaluations

Please indicate all evaluations requested. The assessment team will determine the specific assessments required to address the referral questions.

Academic achievement / achievement testing

Cognitive / intellectual assessment

Speech-language assessment

Occupational therapy assessment

Physical therapy assessment

Behavioral / functional behavior assessment

Social-emotional screening / mental health

Medical review / health screening

Other:

Educational & Support History

Current Supports (check all that apply)

Individualized Education Program (IEP)

Section 504 plan

English language services (ESL/EL)

Tutoring / intervention services

If IEP/504, Case Manager or Coordinator IEP/504 Date:

Medical & Developmental History

Emergency Contact:    Phone:

Records Release & Consent

I authorize release of relevant educational, psychological, medical, and therapeutic records to the evaluation team for the purpose of conducting the requested assessment(s). Records provided will be used solely for evaluation and educational planning and will be maintained in accordance with applicable confidentiality requirements. This authorization permits contact with prior schools, healthcare providers, and service providers as necessary to obtain records and clarifying information.

I consent to release records to the evaluation team

Scheduling & Location Preferences

Preferred evaluation location:

School site

Home visit

Clinic / off-site

Acknowledgments & Authorizations

By checking the box below and signing, I acknowledge that I am the student (if age 18 or older) or the parent/guardian or legal representative of the student and that I have the authority to provide consent for the requested evaluation. I understand that completion of an evaluation does not in itself guarantee eligibility for services, placement, or funding. I understand that evaluation reports will be provided as required by applicable policy and that I may request clarification of results from the evaluation team.

I authorize the evaluation described above and attest that the information provided is accurate to the best of my knowledge.

I understand and agree to the acknowledgments and authorizations in this form.

I acknowledge that certain evaluations may carry fees and that I will be informed in advance when fees apply.

Additional notes or instructions to the evaluation team:

Certification

I certify under penalty of perjury that the information supplied on this form is true and correct. I authorize the evaluation team to contact listed providers and to use the information obtained for the purpose of assessment and educational planning in accordance with applicable confidentiality standards.

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