The School Board of St. Lucie County, Florida
Notice/Consent for Formal Individual Evaluation
To the Parent(s) or Adult student:
Student I.D.#:
School:
Date of Birth:
Date:
A written request has been made for a formal evaluation of your child. This individual evaluation is recommended to assist us in
meeting the educational needs of your child. The evaluation is proposed based on your child’s educational performance and review of
any previous evaluation information which includes _________________________________________________________________
___________________________________________________________________________________________________________
as well as observations and conferences. If other factors were considered in this proposal, these included ______________________
___________________________________________________________________________________________________________
The following checked educational options have been considered or used with your child:




Title I
Change in Level of Instruction
Dropout Prevention
Other _______________________
 Behavior Management
 Change in Instructional Methods
 Tutoring
 Counseling
 Community Agency Referral
The option(s) were determined insufficient to meet the educational needs of your child and have been rejected as the primary
method(s) of assisting your child.

The tests listed may include but not be limited to:
Academic/Preacademic Achievement
 Speech and/or Language
Purpose: To assess current reading, spelling and arithmetic or prereadiness skills such as matching or sorting.

Purpose: To assess communication skills, language ability,
articulation skill, fluency and voice quality.
Intellectual Functioning
Purpose: To assess how well a student remembers what (s)he has seen
and heard, how well (s)he uses information and how (s)he solves
problems. The tests also reflect learning rate and assist in predicting
how well (s)he may do in school. Verbal and/or Performance
measures are used when appropriate.


Hearing
Purpose: To assess a student’s visual ability.
Purpose: To assess a student’s hearing ability.
 Occupational Therapy
Purpose: To assess the areas of fine motor, gross motor,
sensory motor, perceptual, and daily living skills as they may
interfere with the student’s academic/classroom performance.

Social Adjustment
Purpose: These scales of development help to assess social and
behavioral ability.

Vision
Perceptual-Motor Functioning
Purpose: To assess how well a student coordinates body movements
in both small and large muscle activities and assess visual and auditory
channels for learning.



Functional Behavior Assessment
Purpose: An assessment process by which the controlling
Environmental variables (functions) of behavior are identified.
Physical Therapy
Purpose: To assess the areas of general physical function, gross motor
skills and developmental milestones.
Other (specify type needed)_____________________________________
_______________________________________________________
The results of any evaluations paid for by St. Lucie County
School district will be released to the district.
 Personality/Emotional Functioning
Purpose: To assess how the student perceives the world, self and
others, and assess emotional need. May involve Functional Behavioral
Assessment.
Parent/Guardian/Student 18 years or older, must complete the following:
One of these MUST be checked:  I consent to the evaluation,
and have received a copy
of the procedural safeguards.
 I do not consent to the evaluation
Signature:
Date:
and have received a copy of the
procedural safeguards.
 I request a
conference before
giving permission
for the evaluation.
Telephone:
Home:
Work:
You have specific rights concerning the proposed evaluation. The rights are explained in the attached procedural safeguards.
For a further explanation of these rights, contact the school counselor or ESE chairperson.
I have received a copy of the procedural safeguards: Parent Initials ________________ Date ____/____/____
If the native language of the parent/adult student is other than English, a translator was provided.  Yes  No
White: Cum File or ESE Audit File
Canary: Parent/Adult Student
Pink: Evaluation Specialist
XED0041 Rev. 9/02