• Evaluation Team Planning

  • Type of Evaluation

  • Demographics

  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender*
  • Race
  • Grade Level*

  • Corporation & School

  • Corporation*
  • GJCS School*
  • SWD School*
  • NED School*
  • SED School*
  • NS School*
  • SS School*
  • CA School*
  • TC School*
  • Perry Central School*
  • Pike County School*

  • Referral Information

  • Request made by:*
  • Date of Referral*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Request for evaluation was:*
  • Date the school's decision notice was sent to parent:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Student Information

  • Family Information

  • Custody*

  • Same address as student?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Same address as student?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Consent & Timeline

  • Date school received consent signature:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you personally verified that the parent consent has been uploaded and finalized into PSSP and is in the student's file?*
  • Have you completed the Parental Permission to bill Medicaid AND finalized with the parent's signature?*
  • Is this Evaluation looking at Speech or Language Only?*

  • If YES, Please complete the Medicaid Prescription Form:

    MEDICAID PRESCRIPTION FORM

  • Timeline?*

  • 50 day eval

  • Click this link to view the GJCS compliance calendar.

  • Click this link to view the SWD compliance calendar.

  • Click this link to view the NED compliance calendar.

  • Click this link to view the SED compliance calendar.

  • Click this link to view the NS compliance calendar.

  • Click this link to view the SS compliance calendar.

  • Click this link to view the CA compliance calendar.

  • Click this link to view the TC compliance calendar.

  • Click this link to view the PERRY compliance calendar.

  • Click this link to view the PIKE compliance calendar.

  • 50 Day Compliance Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Reason for 50 day Eval?

  • Suspected Eligibility Areas*

  • By Next Annual Review

  • Annual Review Compliance Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Suspected Eligibility Areas*

  • Team Planning

  • Who needs to be involved?*

  • Direction for Evaluator

    Please list specific involvement
  • Will an FBA be a part of this eval?*

  • Reports MUST be uploaded by:

  • Date reports must be uploaded by*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Prescription Provider

    School Psychologist
  • Referral is for?
  • Should be Empty: