Student PPS Form

STUDENT PPS FORM

This Pupil Personnel Services (PPS) Referral and Consent form initiates evaluation, planning, and provision of specialized supports for the student named below. Completion of this form documents the reason for referral, relevant history, requested assessments, and the parent/guardian or adult student's consent or refusal. Submitting this form does not by itself change educational placement; it begins the process required by applicable education law and district policy.

Student Information

Student Name:    Date of Birth:

Student ID:    Grade/Program:

School:    Date of Referral:

Parent / Guardian or Adult Student Contact

Referral and Reason for PPS Review

Academic concerns (reading, math, written expression)
Behavioral or emotional concerns
Speech / language concerns
Health / medical concerns affecting learning
Attendance / chronic absenteeism
Other

Educational History and Interventions

Yes — IEP in effect previously
Yes — 504 plan in effect previously
No prior IEP or 504

Medical / Developmental Information

Hearing concerns: Yes    No
Vision concerns: Yes    No

Suspected Areas and Requested Assessments

Specific Learning Disability
Speech-Language Impairment
Emotional Disturbance
Other Health Impairment
Autism Spectrum Disorder
Intellectual Disability
Other

Psychological assessment
Academic achievement testing
Speech and language evaluation
Occupational therapy evaluation
Physical therapy evaluation
Functional behavioral assessment/behavior observation
Vision screening/evaluation
Hearing screening/evaluation
Medical evaluation or records review
Other

Confidentiality, Records, and Release of Information

By completing and signing this form I authorize the school and its authorized agents to conduct the assessment activities checked above, to review and obtain copies of relevant educational and medical records, and to communicate with prior schools, physicians, therapists, and other providers as necessary to complete a comprehensive evaluation. Assessment reports and related records will be maintained in the student's education record and disclosed only to individuals with legitimate educational interest or as otherwise permitted by law.

Consent for Evaluation

Consent selection: I consent to the requested evaluation(s) and release of records as described above.   I do not consent to the requested evaluation(s). I understand that refusal to consent will prevent those assessments from being conducted, but does not prevent the district from providing other supports or from conducting assessments required by law without consent where lawful.

I understand that:

• Assessment results and recommendations will be shared with me and with staff who have a legitimate educational interest.
• I will be provided timely notice of any eligibility determination and proposed educational placement resulting from these evaluations.
• I may withdraw consent in writing at any time, and such withdrawal will not affect actions already taken based on my prior consent.

School Use Only (Record of Processing)

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