Student Eval Request Letter

STUDENT EVALUATION REQUEST LETTER

Use this form to request a formal educational evaluation for the purpose of eligibility determination, instructional planning, and/or therapeutic recommendations. Complete every section and sign the authorization at the end. Submission of this request constitutes written authorization for the school to begin intake review and, where required, to seek pertinent educational and medical records necessary to conduct a comprehensive evaluation.

Student Information

Parent / Guardian or Adult Student Contact

Evaluation Requested (check all that apply)

Requested Evaluation Types Psychoeducational assessment
Functional behavior assessment (FBA)
Speech and language evaluation
Occupational therapy evaluation
Physical therapy evaluation
Academic achievement / processing assessment
Other:

Reason for Referral

Please provide specific, observable concerns and examples of how these concerns affect the student's educational performance. Include duration and who first observed the concern.

Supporting Documentation

Check all records provided or available to be obtained for review.

Current IEP
504 Accommodation Plan
Prior evaluations or reports (psychological, speech, medical)
Medical or psychiatric records relevant to learning or behavior
Academic records / transcript
Other documents (describe):

Educational and Medical History

Authorization and Consent

By checking the authorization box and signing below, I authorize the educational institution and its contracted providers to:

1. Obtain and review educational, medical, and prior evaluation records necessary to conduct a comprehensive evaluation;
2. Administer standardized and non-standardized assessments, observations, and interviews relevant to the requested evaluation;
3. Share evaluation results with multidisciplinary team members for the purpose of determining eligibility and developing educational programming.

I authorize the release and exchange of records and the conduct of the requested evaluation as described above.

I consent to audio and/or video recording of assessment sessions when deemed necessary by evaluators for scoring, review, or training purposes.

Preferred Logistics

Important Notices

The results of the evaluation will be shared with the requesting school personnel and other designated professionals involved in the student's education. Evaluation reports are educational records and will be maintained consistent with the institution's record-keeping policies. Refusal to sign does not preclude the school from conducting an evaluation when otherwise permitted or required by applicable educational procedures; however, lack of authorization may limit access to outside records necessary for a complete assessment.

I understand that submission of this request does not automatically result in eligibility for special education or other services; eligibility is determined by the multidisciplinary team after review of assessment results and records.

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