Evaluation Request Form - Early Learning Center and Lower School

Evaluation Request Form Early Learning Center and Lower School

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~Student~ Page 1 of 12



Student Information




Student 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) 972-7573 or evaluations@perkins.org

~Additional Contacts~ Page 2 of 12

Parent or Guardian




must be unique for each contact

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

Additional Parent or Guardian
Additional Parent/Guardian




must be unique for each contact

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

School District Contact/Other Contact






must be unique for each contact

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


While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Medical Information~ Page 3 of 12

Birth History







Additional Medical and Health Conditions





Physical Exam and Hospitalizations




Seizures






While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Medical Information Continued~ Page 4 of 12

Medications (*To add another medical condition use the Add Another Medication link below) 


Vision Information
Primary visual diagnosis as determined by medical reports:
















Hearing Information






While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Communication Information~ Page 5 of 12










While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Social-Emotional / Behavior Information~ Page 6 of 12















While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Mobility Information~ Page 7 of 12













While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org


Toileting:


Food Eating / Diet /Mealtime
















Dressing





While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Additional Student Information~ Page 9 of 12
Sensory Motor Integration












Educational Information


Pre-Braille / Compensatory Skills (please complete for children 6 and under)










Please answer the following questions if the child is 5 and older:












While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Additional Student Information~ Page 10 of 12
Support Services





















While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Evaluation Questions and Concerns~ Page 11 of 12

Psychological Evaluations
Psychological evaluations at Perkins are conducted by school psychologists. They include a set of procedures to obtain information about a student’s cognition, social-emotional development and adjustment, and adaptive behavior. Cognitive functioning refers to skills such as verbal reasoning and concept development, problem solving/reasoning, attention, and memory. Social-emotional development and adjustment includes social skills, temperament, coping skills, and emotional/behavioral regulation.  Adaptive behavior refers to a student’s level of functioning in activities of daily living. 

Assessment procedures may include standardized tests, rating scales, developmental assessment, informal assessment activities/observations, and interviews. Assessment procedures are determined on an individual basis taking into consideration the student’s abilities and the referral questions and concerns.

Educational Evaluations
An educational evaluation at Perkins is conducted by a teacher of students with visual impairment (TVI) or deafblind teachers. The evaluation includes planned activities to obtain information about the student’s educational achievement in areas such as concept development, compensatory skills (taking into consideration the expanded core curriculum), literacy and math development, learning strengths, and areas of need. Evaluation activities and procedures are individually developed for each student based on their developmental presentation and submitted evaluation questions and concerns. Assessment procedures may include standardized tests, rating scales, developmental assessments, informal assessment activities/observations, and interviews. Assessment may be conducted in braille or large print or with alternative methods of communication such as Total Communication, as appropriate for each individual student. Based on evaluation findings, student-specific recommendations are made to help with educational programming and to promote the student’s educational advancement.

Speech and Language Evaluations
Speech-language pathologists provide assessment in the areas of speech production (i.e., articulation, voice, and fluency), receptive and expressive language, and pragmatic communication (i.e., social use of language). Additionally, an alternative and augmentative communication (AAC) screening and/or an observation of a student’s feeding skills can be provided. Referrals will be made for more comprehensive AAC and feeding evaluations if needed. 

Assessment procedures may include standardized tests, informal assessment activities/observations, and interviews. Assessment procedures are determined on an individual basis, taking into consideration the student’s abilities and the referral questions and concerns

Occupational Therapy Evaluations
At Perkins, occupational therapy evaluations assess various areas of a student’s development as they relate to participation in daily routines and educational activities. These assessments take a holistic approach with a specific emphasis on the unique needs of students with visual impairment and/or deafblindness. Based on the individual needs of each student, assessment areas may include: cognitive-perceptual skills; sensory functions; gross, fine, and visual motor skills; executive functioning; classroom participation; and self-care/independent living skills. Cognitive-perceptual skills refer to the thinking processes of receiving, interpreting, and organizing stimuli to determine a response. Sensory functions involve use of vision, hearing, touch, smell, taste, vestibular (i.e., movement and balance information received from receptors in the inner ear), and proprioception (i.e., body position information received from receptors in the joints and muscles). An occupational therapist evaluates a student’s ability to process input from all of these sensory systems in order to maintain a calm, regulated, and alert state for learning and participation in activities. Executive functioning involves mental skills such as memory, flexible thinking, and self-control. Based on evaluation findings, student-specific recommendations are made to maximize independence. In addition, the occupational therapist may make recommendations regarding modifications to materials, equipment, and the environment to further maximize independence. 

Assessment procedures may include record review, standardized tests, rating scales/questionnaires, informal assessment activities/observations, and interviews. Assessment procedures are determined on an individual basis taking into consideration the student’s abilities and the referral questions and concerns.

Physical Therapy Evaluations
The purpose of a school-based physical therapy evaluation is to identify a student’s motor development strengths and needs, particularly in regards to their ability to participate in meaningful school activities and routines, which aim to prepare students for further education, employment, and independent living, with or without assistance. Assessment areas may include gross motor, neuromuscular (i.e., muscle tone, balance, sensorimotor, motor planning), and musculoskeletal (i.e., muscle strength, range of motion, posture, gait) skills, as well as use of adaptive devices and equipment. Assessment procedures are determined on an individual basis, taking into consideration the student’s abilities and the referral questions and concerns. 

Assessment procedures may include record review, use of formal assessment tools, informal assessment activities/observations, and interviews. Based on the evaluation results, student-specific recommendations are made to maximize participation and independence in accessing the student’s curriculum. 

Orientation and Mobility Evaluations
An orientation and mobility (O&M) evaluation seeks to describe a student’s current performance in travel skills in order to provide recommendations regarding O&M instruction. The evaluation process includes record review, assessment activities/observations, and interview. 

O&M is taught by a certified orientation and mobility specialist (COMS). A COMS teaches independent travel skills to people who are blind or visually impaired. Some areas of focus include, but are not limited to: white cane skills; protective techniques for moving without a cane; learning routes of travel to access different places in your home, school, and community; use of public transportation; and recovery techniques if one becomes lost. One does not need to be ambulatory to receive orientation and mobility services, but one should be able to move safely at an age-appropriate level with some degree of independence to benefit from services (for example, follow a voice guide or verbal directions). 

The O&M curriculum is presented in a developmentally appropriate way, with the emphasis of instruction on the student’s current capacity and potential for independence. However, not all students will become independent travelers in their future. The goal is to help each student work towards the highest level of independence that they can safely attain.

Cortical/Cerebral Visual Impairment (CVI)


Upon completion of this form, you will receive an email with a link to complete a short Educational Assessment specific to Cortical/Cerebral Visual Impairment (CVI). 



While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~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.  Any additional reports can be included as "Other File". 

Refer to the 
Required Paperwork Checklist for all necessary application materials.
Submit evaluation materials here or by mail, email or fax.

The following file types are accepted:
  • .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)
Mail - Evaluations Department, Perkins School for the Blind, 175 North Beacon St.
Watertown, MA 02472
Email - evaluations@perkins.org
Fax - (617) 972-7715
Image Upload  
The following image types are accepted:
  • .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) 972-7573 or evaluations@perkins.org