Evaluation Request Form - Secondary 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) 972-7573 or evaluations@perkins.org

Evaluation Request Form Secondary School
~Additional Contacts~ Page 2 of 10

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/Other Contact







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

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

Evaluation Request Form Secondary School
~~Vision/Speech/Hearing~  Page 3 of 10

Vision

Visual acuity




(i.e., visual field deficits, Cortical/Cerebral Visual Impairment (CVI), recent or progressive loss of vision, etc.)
Hearing



(cochlear implants, FM unit, etc.)

Speech and Language




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

 ~Occupational Therapy~ Page 4 of 10






Does he/she need assistance for basic self care? Please describe:



Does he/she need assistance for independent living activities?








Does he/she appear sensitive (or has ever in the past) to:






Does he/she seem to (now or in the past):





Evaluation Request Form Secondary School
~Educational Information~  Page 5 of 10

Educational Information


(please describe)


Educational Supportive Services

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

Evaluation Request Form Secondary School
~Social/Behavioral~  Page 6 of 10

Social Skills

Social/Emotional

Behavior and Adjustment


Orientation and Mobility

(include the use of mobility aids)



Physical Therapy



Daily Living Skills

(including eating, dressing, toileting, and use of adaptive equipment)

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

Evaluation Request Form Secondary School
~Medical Information~  Page 7 of 10

Diagnoses

Allergies

Medical History


Seizures



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

Evaluation Request Form Secondary School
~ Medications and Additional Information~  Page 8 of 10


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


Additional Medical Information


(medical devices/equipment)

Behavorial History

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) 972-7573 or evaluations@perkins.org

Evaluation Request Form Secondary School
~Evaluation Questions and Concerns~  Page 9 of 10


Psychological Evaluations
Psychological evaluations at Perkins are conducted by school psychologists. They include a set of procedures to obtain information about a student’s cognitive functioning, 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 assessments, 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.

Behavioral Screening
A behavioral screening at Perkins is conducted by a behavior analyst who has experience working with students with visual impairment or deafblindness. It may also be completed in collaboration with a Perkins’ school psychological evaluation. The screening includes record review, direct observation during the student’s evaluation visit to Perkins’ campus, and parent interview. Taking into consideration a positive behavioral approach, a written summary is provided with recommendations for additional assessment and general behavioral support. Given the limitation of time and where the evaluation takes place, this screening does not include a functional behavior assessment nor behavior analysis. 

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). 
Questions

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

Evaluation Request Form Secondary School
~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.

General File Upload 
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.
Additional reports can be included as “Other File”.

Refer to the Required Paperwork Checklist for all necessary application materials.

Attach evaluation materials here or submit by mail, email, or fax:

 

Mail: Evaluations Department

          Perkins School for the Blind, 

          175 North Beacon St. 

          Watertown, MA 02472 

Email: Evaluations@Perkins.org 

Fax: (617) 972-7715


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) 972-7573 or evaluations@perkins.org