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) 972-7571 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) 972-7571 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) 972-7571 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) 972-7571 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) 972-7571 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) 972-7571 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) 972-7571 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) 972-7571 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) 972-7571 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) 972-7571 or evaluations@perkins.org
~Evaluation Questions and Concerns~ Page 11 of 12




While filling out this form, if you have any questions please contact us at (617) 972-7571 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"
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)
Image Upload  
The following image types are accepted:
  • .bmp (Bitmap)
  • .jpg (JPEG)
  • .gif (Graphics Interchange Format)
  • .png (Portable Network Graphic)
  • .tif (Tagged Image Format)
Permission and Privacy Statement



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