School Request Form for Services
Student's Name
*
Gender:
Please Select
Male
Female
DOB
*
Classification
if applicable (e.g. IEP or 504)
School Name
*
Grade
School District Name
Phone Number
Fax Number
optional
Case Manager's Name
*
Case Manager's Email
*
example@example.com
Teacher's Name
*
Teacher's Email
*
SLP's Name
*
If aplicable
SLP's Email
*
If aplicable
Evaluation Services
Rows
Desired Service
Date Requested
Comments
Speech-Language Evaluation
Speech-Articulation & Voice Evaluation
Speech-Language & Articulation Evaluation
AAC (Augmentative Alternative Communication) Evaluation
AT (Educational Assistive Technology) Evaluation
Deaf/Hard of Hearing, Speech-Language & Articulation Evaluation
Physical Therapy Evaluation
Occupational Therapy Evaluation
Feeding Evaluation
Therapy Services
Rows
Desired Service
Dates Requested (start/end)
Frequency
Comments
Speech Language Therapy
Speech Language Therapy (Block Bill [more than 4hr])
Occupational Therapy
Occupational Therapy (Block Bill [4hr+])
Physical Therapy
Feeding Therapy
Behavioral Therapy
1 on 1 Aide
Consultative Services
Rows
Desired Service
Dates Requested (start/end)
Frequency
Comments
Augmentative Alternative Communication (AAC)
Educational Assistive Technology (AT) (including HAT - hearing assistive tech)
Itinerant Teacher of the Deaf (TOD)
Feeding consult
Other Services
Rows
Desired Services
Dates Requested (start/end date)
Frequency (hours/days)
Comment
ASL interpreting
Communication Aide
Workshop
AAC Device Rental
(Must receive consultative services through Elevate Health)
AT/HAT Rental (e.g. FM System)
Parent Training for AAC Device
Teacher Training for AAC Device
I have entered the duration and frequency for therapy/consult:
YES
N/A
Students Room Number:
(If possible, this is helpful for clinicians)
Additional Comments
Students nap time, specials, or any other helpful details
For evaluations: Please indicate the date by which this evaluation must be completed and submitted to remain in compliance (if applicable, otherwise enter N/A)
*
I understand that, upon receipt of this form, the student’s case manager or principal will be contacted with further information. Please upload the student's records (e.g. IEP, recent evaluation reports) to allow for services for start.
*
Yes
No
The director has approved this request
*
yes, move forward
not yet, and I understand the director/secretary will be contacted to confirm
File Upload
*
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