IATP: School AT/AAC Evaluations

Complete The Following for the Person Requesting The Evaluation (District Staff ONLY may be Requestor)

Requestor Name (Required):

Requestor Phone (Required):

Requestor Email (Required):

Contact Info for Point Person (This Individual Will be Responsible for Filling out Information Packet)

Check to copy requestor information to contact fields

Contact Name (Required):

Contact Phone (Required):

Contact Email (Required):

County (Required):

School District (Required):

Complete this Section for the Student who will Receive the Evaluation

Student Name (Required):

Student Age (Required):

Date of Birth (Required):

Grade Level (Required):

Sex (Required):

Ethnicity (Required):

Disability Category (Required):

Disability (Required):

School

School (Required, populates school fields):

Name (Required for New School):

School Address (Required):

State (Required):

City (Required):

Zip Code (Required):

School Phone (Required):

State the Reason for Referral and the Goal of Evaluation

Referral Reason (Required)

Evaluation Goal (Required)

Evaluation Type

Due to Covid-19 restrictions we are offering remote evaluations in addition to our standard in-person visits. All precautions will be taken for physical visits, including masks, gloves, and gowns (if necessary). Please select the type of evaluation preferred.

Evaluation Type (Required):

In-Person Evaluation

Tele-Evaluation

Release of Information / Disclaimer

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