Evaluation Matters Request for Services Form

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Please complete this form for Advocacy, Consultation or Educational Assessment requests. This form will be used as an intake form and does not serve as a commitment or agreement of requested services. Additional information will be gathered upon further consultations. If you have difficulty using this form or need assistance, you may email us @ evaluationmattersllc@gmail.com.

Primary Contact Information (Name & Phone) *

Source of Referral *

Parent/Guardian

School District

Other:

Required

Child's Grade *

Is your child attending a Public, Private or Non-Public School? *

Public School

Private School

Non-Public School

Required

Services Requested. *

FREE 30 Minute NO COST, NO OBLIGATION phone consultation.

Consultation ($125/hr)

Advocacy ($125/hr)

Educational Assessment & Evaluation (Ranges from $550-$1200. Cost is based on requested evaluations.)

Brief description of your concerns. (Optional)

Submit

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