Educational Evaluation- SSS

Student Support Services
Student's Full Name*
Grade Entering*
Has your student ever been EVALUATED or REFERRED for evaluation for academic/learning, physical, or mental difficulties that may include the following (check all that apply):

ADD/ADHDAnxiety DisorderAutism Spectrum DisorderBehavioral DisabilityDevelopmentally DelayedDual Sensory ImpairmentEmotional DisabilityHearing ImpairmentIntellectual DisabilityLearning Processing DisabilityPhysically HandicappedSpecific Learning DisabilitySpeech/Language ImpairmentSpina BifidaVision ImpairmentOther
Please briefly describe and give dates for any boxes checked
List any current medications and dosage:
I will inform FCA of any doctor or parental changes (i.e. therapy, medicine for my child) by contacting Student Support Services during the school year.
Parent/Guardian Initials*

Clear
Do you have an of any of the following? (Check all that apply and attach a copy of all evaluations below)

IEP504 PlanGeneral Doctor ReportNeurological ReportPsychoeducational ReportPsychological ReportOther
Date of Diagnosis/Evaluation*

MonthDayYear
Date
Next Update Due by

MonthDayYear
Date
Additional instructions for obtaining an updated evaluation:
Will be filled out by SSS team if needed
Please attach copies of any OFFICIAL evaluations your child may have received (evaluations must be current- no older than 3 years):

Cancelof
Evaluations and diagnoses must be updated at minimum every three years. I agree to provide these professional documents.
Parent/Guardian Initials*

Clear
Parent/Guardian Name*
Parent/Guardian Email*
example@example.com
By signing below, I certify that the information I have provided is true and correct to the best of my knowledge.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Student Support Services