Service Request Form

Your Name
Email
School District
Student
Birth Date
Contact for additional info
Requested Completion Date
Teacher
School/Class

Discipline Requested:

Speech-LanguageOccupational TherapyPhysical Therapy

Services Requested

ObservationScreeningEvaluationDirect TherapyConsultationParent Training
Other:

Does the child have a current IEP? YesNo

Has the child been evaluated or received services in the past? YesNo

If you need IEP information or an evaluation report, when is the IEP meeting?

Date parent's signature was obtained
Area(s) of Concern
Speech/Language

ArticulationOral-motor skillsVoiceFluency
Other:

Occupational Therapy

Fine MotorVision/PerceptionSensory Integration
Other:

Language

ComprehensionExpression of ideasSocial skills

Physical Therapy

BalanceCoordination
Other:

Describe the specific concerns with the child