Evaluation Request Form - Secondary Program

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~Student~  Page 1 of 9


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 Secondary School
~Additional Contacts~ Page 2 of 9

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 Secondary School
~~Vision/Speech/Hearing~  Page 3 of 9

Vision

Visual acuity




(i.e., visual field deficits, cortical vision impairment, 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) 972-7571 or evaluations@perkins.org

Evaluation Request Form Secondary School
~Educational Information~  Page 4 of 9

Educational Information


(please describe)


Educational Supportive 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 Secondary School
~Social/Behavioral~  Page 5 of 9

Social Skills

Social/Emotional

Behavior and Adjustment

Orientation and Mobility

(include the use of mobility aids)
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) 972-7571 or evaluations@perkins.org

Evaluation Request Form Secondary School
~Medical Information~  Page 6 of 9

Diagnoses

Allergies

Medical History


Seizures



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

Evaluation Request Form Secondary School
~ Medications and Additional Information~  Page 7 of 9


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


Additional Medical Information


(medical devices/equipment)

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 Secondary School
~Evaluation Questions and Concerns~  Page 8 of 9

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 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.

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