Special Education Evaluation Request
Parents/Guardians who have a concern about their child's development or have a suspicion about a possible disability may refer their child for an initial evaluation. Upon receipt of a request for an initial evaluation, the school district will send notice to the parent/guardian to obtain the parent's consent to conduct an evaluation.

The information collected on this intake form will provide the necessary information to create a referral in the Special Education Database and to help to identify areas of concern. 

Email *
Child's First and Last Name *
Child's Middle Name *
Child's Date of Birth *
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Town of Residence *
Street Address *
Child's City of Birth *
Parent/Guardian One - Name *
Parent/Guardian One - Address *
Parent/Guardian One - Phone Number *
Parent/Guardian One - Email *
Parent/Guardian Two - Name
Parent/Guardian Two - Address
Parent/Guardian Two - Phone Number
Parent/Guardian Two - Email
Please describe, in as much detail as possible, your areas of concerns.  This information will provide valuable background information to the school based evaluators.  *
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