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Request for OT Support
Certified teachers (general and special education) can request OT support or consultation of a student. Please complete this form in order to receive timely and meaningful OT consultation.
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* Indicates required question
Student's name (first and last)
*
Your answer
Grade level of student
*
Your answer
Attendance center (where does child attend school?)
*
Choose
JC Jefferson
JC Lincoln
JC Washington
JCHS
Adams School
Longfellow
Marion Jefferson
Marion Lincoln
Marion Washington
MJHS
MHS
The Learning Center
Crab Orchard Schools
Northside Primary Center
Herrin Elementary
HJHS
HHS
LLPC
TriC Elementary
Carterville Intermediate
CJHS
CHS
Is the child new to the district?
*
YES
NO
Does the student have an IEP?
*
YES
NO
Does the student currently receive OT services?
*
YES
NO
Name of contact person to schedule observation/consultation
*
Your answer
Email address of contact person
*
Your answer
Briefly describe the reason for OT consultation
*
Your answer
Name of person completing this form
*
Your answer
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