Evaluation Form - Cortical/Cerebral Visual Impairment (CVI)

Page 1

Student




Address






Parent/Guardian Information





Parent/Guardian 2 Information





Student Information Essential to Assessment



If you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

Page 2 - Required Documents

Please attach all required documents. If preferred, you can also use the address below to mail or email documents after submitting this form. Please note, the student's referral is not complete until all required documents are submitted.

Documents Required
  • Eye doctor report
  • Neurology report and MRI report (if available)
  • Psychology or neuropsychological report (if available)
  • Current IEP / IFSP
  • Report from Teacher of Students with Visual Impairment (TVI) (e.g., functional vision report, learning media assessment, and/or annual report)
  • Picture of the student 
  • Video(s) of student* 
Mail:  Evaluations Department 
Perkins School for the Blind 
175 North Beacon Street 
Watertown, MA 02472

Email: Evaluations@Perkins.org

*Please email videos to evaluations@perkins.org
Attachments








File types that can be uploaded for documents:
  • .doc (Older Microsoft Word format)
  • .docx (Current Microsoft Word format)
  • .xls (Older Microsoft Excel format)
  • .xlsx (Current Microsoft Excel format)
  • .ppt (Older Microsoft Powerpoint format)
  • .pptx (Current Microsoft Powerpoint format)
  • .pdf (Adobe PDF)
  • .odt (Open Office word processor document)
  • .ods (Open Office spreadsheet document)
  • .odp (Open Office presentation document)
  • .pages (Apple Productivity Pages document)
  • .keynote (Apple Productivity Keynote document)
  • .numbers (Apple Productivity Numbers document)
File types that can be uploaded for images:
  • .bmp (Bitmap)
  • .gif (Graphics Interchange Format)
  • .jpg (Joint Photographic Experts Group)
  • .jpeg (Joint Photographic Experts Group)
  • .png (Portable Network Graphics)
  • .tif (Tagged Image File)

If you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

Page 3 - Payment Information

Assessment Payment

Cost: $1,200.00

School Contact Information
If school funded, please provide contact information below to set up billing. 




District or School



School Contact Email Address

District or School Country

District or School Address

District or School City

District or School State


District or School Zip/Postal Code

If you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org