Form 1 - Data For Possible Initial Educational Evaluation printable pdf download

D-S-P Co-op Form 1

_____ Speech

Completed by Teacher

_____ Preschool

Revised: 06/08 Updated: 05/11

_____ Other

DATA FOR POSSIBLE INITIAL EDUCATIONAL EVALUATION

DUBOIS-SPENCER-PERRY EXCEPTIONAL CHILDREN’S CO-OP

1520 ST. CHARLES STREET, SUITE 2

319 S. 5TH STREET, ROOM 15

JASPER, IN 47546

ROCKPORT, IN 47635

PHONE: (812) 482-6661

FAX: (812) 482-9381

PHONE: (812) 649-9991 FAX: (812) 649-9997

Initial Referral:

______ School Initiated

______ Parent Initiated (Copy of written request attached)

Preschool Referral Source: ____First Steps ____Parent

____Physician ____Other____________

Has this student been previously referred for speech or other educational evaluation? ____ No ____ Yes

_________________

(date)

Student Name ____________________________________________ DOB _________________________

Student Test Number______________________________________________________

Gender ____Male

____Female

Race/Ethnic (Check one below)

____ American Indian or Alaskan Native ____ Asian or Pacific Islander ____ Hispanic ____ Black ____ White ____ Multiracial

Student’s Primary Language ______________________ Parent’s Primary Language __________________________

Grade ____ School ___________________________________________ Teacher _____________________________________

Parent/Legal Guardian Name & Address________________________________________________________________________

Parent Home Phone___________________ Parent Work Phone___________________ Cell Phone_______________________

Address if not living with parents _____________________________________________________________________________

Parent email address ______________________________________________________________________________________

List Medical, Mental Health or Social Services personnel who have evaluated and/or provided services to this student, such as:

physicians, therapists, counselors, or case workers. INCLUDE RELEASE OF INFORMATION FORM #13.

Name

Agency

Please check Suspected Educational Disability(ies)

___Autism Spectrum Disorder

___ Developmental Delay

___ Orthopedic Impairment

(Early Childhood)

___ Blind or Low Vision

___ Emotional Disability

___ Specific Learning Disability

___ Cognitive Disability

___ Language Impairment

___ Speech Impairment

___ Deaf-Blind

___ Multiple Disabilities

___ Traumatic Brain Injury

___ Deaf or Hard of Hearing

___ Other Health Impairment

Please identify the specific problems and concerns that cause you to suspect the education disability(ies) checked above:

How does this adversely affect the student’s academic or functional progress?

What were the student’s universal screening scores as compared to his peers?

_____________________________________________________________________________________________________

Form 1 - Data For Possible Initial Educational Evaluation

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