IATP: School AT/AAC Evaluations

Requestor Name (Required):

Requestor Phone (Required):

Requestor Email (Required):

Relationship to Student (Required):

Requestor County (Required):

Requestor District (Required):

Check if same as requestor

Contact Name (Required):

Contact Phone (Required):

Contact Email (Required):

Contact Relationship to Student (Required):

County (Required):

School District (Required):

Student Name (Required):

Student Age (Required):

Date of Birth (Required):

Grade Level (Required):

Sex (Required):

Ethnicity (Required):

Disability Category (Required):

Disability (Required):

List of schools below changes based on the District selected for Contact Info.

School (Required, populates school fields):

Name (Required for New School):

School Address (Required):

State (Required):

City (Required):

Zip Code (Required):

School Phone (Required):

Referral Reason (Required)

Evaluation Goal (Required)

Evaluation Type (Required):

In-Person Evaluation

Tele-Evaluation

I Authorize the Release of my Information as Submitted in the Referral Package (Required)