Evaluation Request Form - Deafblind Program

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~Student~  Page 1 of 10


Student



ex: 1/2/2005

Address






If you have applied to Perkins within the last 6 months, please contact our office before submitting any documents other than this application.

While filling out this form, if you have any questions please contact us at (617) 972-7571 or evaluations@perkins.org

Evaluation Request Form Deafblind Program
~Additional Contacts~ Page 2 of 10

Family Contact (*To add another family contact use the Add Another Family Contact link below this box)




must be unique for each contact

ex: ###-###-####

School District/Other Contact







ex: ###-###-####

While filling out this form, if you have any questions please contact us at (617) 972-7571 or evaluations@perkins.org

Evaluation Request Form Deafblind Program
~Vision/Speech/Hearing~  Page 3 of 10

Vision

Visual acuity








(i.e. telescope, magnifier, etc.)



Hearing






Type of amplification device






While filling out this form, if you have any questions please contact us at (617) 972-7571 or evaluations@perkins.org

Evaluation Request Form Deafblind Program
~Communication and Mobility~ Page 4 of 10

Communication Skills (Expressive, Receptive, and Pragmatic Language)








i.e. sign langue, speech, aug. device, etc



Mobility



While filling out this form, if you have any questions please contact us at (617) 972-7571 or evaluations@perkins.org

Evaluation Request Form Deafblind Program
~Medical Information~  Page 5 of 10

Medical History
Diagnoses (*To add additional diagnoses use the Add Another Diagnosis link below this box)








Medications list (*To add additional medications use the Add Another Medication link below this box)



Seizure medications list (*To add additional medications use the Add Another Seizure Medication link below this box)



Seizures




Additional Medical Information


(medical devices/equipment)

While filling out this form, if you have any questions please contact us at (617) 972-7571 or evaluations@perkins.org

Evaluation Request Form Deafblind Program
~Eating and Daily Living~  Page 6 of 10

Eating









Please remember to attach the student's swallow study in the uploads section on the last page of this form 
Daily Living Skills




While filling out this form, if you have any questions please contact us at (617) 972-7571 or evaluations@perkins.org

Evaluation Request Form Deafblind Program
~Adaptive Equipment, Behavioral/Mental Health Information~  Page 7 of 10

Adaptive Equipment


Behavioral/Mental Health Information



Please attach the student's behavior plan in the uploads section on the last page of this form




While filling out this form, if you have any questions please contact us at (617) 972-7571 or evaluations@perkins.org

Evaluation Request Form Deafblind Program
~Educational Information~  Page 8 of 10

Educational Information


Supportive Services



















Additional Information

(for example, Infant/Toddler Program, Outreach, New England Center for Deaf Blind)

(affiliated Perkins services)

While filling out this form, if you have any questions please contact us at (617) 972-7571 or evaluations@perkins.org

Evaluation Request Form Deafblind Program
~Evaluation Questions and Concerns~  Page 9 of 10


Questions

Concerns

While filling out this form, if you have any questions please contact us at (617) 972-7571 or evaluations@perkins.org

Evaluation Request Form Deafblind Program
~File Uploads~  Final page!

If you have applied to Perkins within the last 6 months, please contact our office before submitting any documents other than this application.

File Upload 
Please upload all available educational, clinical, and medical reports
Additional reports can be included as “Other File”

Submit evaluation materials here or by mail, email, or fax. File types that can be uploaded here:

  • .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)
Image Upload (*To add another image use the Add Another Image File link) 

Image types that can be uploaded here:

  • .bmp (Bitmap)
  • .jpg (JPEG)
  • .gif (Graphics Interchange Format)
  • .png (Portable Network Graphic)
  • .tif (Tagged Image Format)
Release

While filling out this form, if you have any questions please contact us at (617) 972-7571 or Evaluations@perkins.org