RISD Outreach Service Request
Date
*
-
Month
-
Day
Year
Date
We ask that you do not disclose the student's name and date of birth until we have obtained a signed release from the parent or guardian.
LEA:
*
School:
*
Student's Grade
*
Contact Person:
*
Contact's email:
*
example@example.com
How long has the student been at his/her current school?
What type of service are you requesting?
*
In-service training
Team Meeting
IEP Meeting
Assistance with Technology
Consultation on strategies, etc
Direct Service TOD (ex. pre-teaching curriculum)
Direct Service SLP (ex. language assessment)
Direct Service Educational Audiologist (ex. acoustic classroom analysis)
Classroom Observation
Unsure
Other
Are you requesting ongoing or one-time services?
*
Ongoing
One-time
Unsure
Please select any concerns you currently have for this child
*
reading
mathematics
other academic difficulties
social/behavioral difficulties
attention difficulties
following verbal directions
minimal vocabulary
social communication
language structure/grammar
motor difficulties
visual difficulties
speech difficulties
health difficulties
Does the student currently have an IEP/504?
*
IEP
504
NO
Is the student now receiving, or have they ever received, the following services?
physical therapy
occupational therapy
speech therapy
summer school/ESY
counseling
Has the student received the following evaluations?
speech language evaluation
psychological evaluation
audiological evaluation
educational evaluation
occupational therapy evaluation
physical therapy evaluation
Other
What are your expectations following this visit? For example, what do you hope to change, adjust, learn, etc.
What resources do you think would be helpful to you having a student who is diagnosed with hearing loss in your classroom? (optional)
Please list any additional comments or questions you may have:
Thank you! Someone will reach out to you shortly
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