School Request Form for Services
Student's Name
DOB
Classification
if applicable (e.g. IEP or 504)
School
Grade
School District Name
Phone Number
Fax Number
optional
Case Manager's Name
Case Manager's Email
example@example.com
Teacher's Name
Teacher's Email
SLP's Name
If aplicable
SLP's Email
If aplicable
Evaluation Services
Desired Service
Date Requested
Comments
Speech-Language Evaluation
Speech-Articulation & Voice Evaluation
Speech-Language & Articulation Evaluation
AAC (Augmentative Alternative Communication) Evaluation
AT (Educational Assistive Technology) Evaluation
Deaf/Hard of Hearing, Speech-Language & Articulation Evaluation
Audiological Evaluation
Audiological Classroom Observation/Assessment
Therapy Services
Desired Service
Dates Requested (start/end)
Frequency
Comments
Speech Language Therapy
Speech Language Therapy (Block Bill [more than 4hr])
Occupational Therapy
Occupational Therapy (Block Bill [4hr+])
Consultative Services
Desired Service
Dates Requested (start/end)
Frequency
Comments
Augmentative Alternative Communication (AAC)
Educational Assistive Technology (AT)
Educational Audiological/Hearing Aid Technology (HAT)
Itinerant Teacher of the Deaf (TOD)
Other Services
Desired Services
Dates Requested (start/end date)
Frequency (hours/days)
Comment
ASL interpreting
Communication Aide
Workshop
AAC Device Rental
AT/HAT Rental (e.g. FM System)
Additional Comments
I understand that, upon receipt of this form, the student’s case manager or principal will be contacted with further information. Please supply the student’s records (e.g. IEP, recent evaluation reports) to allow for services for start.
Yes
No
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