Evaluation Request Letter for Education

EVALUATION REQUEST LETTER FOR EDUCATION

Student Information

Date of Birth:    Student ID:    Grade / Program:

Requestor / Parent / Guardian Information

Relationship to Student:    Contact Phone:    Email:

Evaluation Requested

Type(s) of evaluation requested (check all that apply):

Academic achievement testing    Psychological / cognitive assessment    Speech / language evaluation

Occupational therapy evaluation    Functional behavior assessment    Vocational assessment

Eligibility determination for special education services    Other:

Requested completion date:    Priority of request:

Supporting Records and Attachments

Please indicate records being provided with this request:

Transcripts    IEP / 504 documents    Prior evaluation reports

Attendance / disciplinary records    Health / medical records    Other:

Authorization and Certifications

By signing below I certify that I am authorized to request this evaluation for the student named above. I authorize the release and review of educational, medical, and behavioral records necessary to complete the requested evaluation. I understand the evaluation report will be shared with school personnel responsible for educational decisions and other identified professionals as required for educational planning.

I understand that:

• Evaluations will be conducted by qualified personnel in accordance with applicable district policies and professional standards.
• Reasonable efforts will be made to complete the evaluation by the requested date; however, timelines may be extended for valid administrative or clinical reasons. I will be notified of any delay in writing.
• There may be fees associated with certain specialized evaluations. Responsibility for payment must be determined prior to services; select below if you agree to assume fees.
• Submitted records will be retained in accordance with institutional records retention policies and applicable confidentiality laws.

I agree to assume financial responsibility for any fees associated with this evaluation if the institution requires payment prior to service.

Legal Acknowledgment

The requester acknowledges that the information provided in this request is accurate to the best of their knowledge. The requester understands that falsification of information may delay or void the evaluation request. This request does not constitute an entitlement to services beyond those determined appropriate following assessment and review by qualified personnel.

Office Use Only

Date Received:    Request Number:

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