“YOUR” COMMUNITY SCHOOLS
CONSENT FOR MULTIDISCIPLINARY EVALUATION
“YOUR” Community Schools – Student Support Services
Date CONSENT is requested:
Date CONSENT is received by Student Support Services:
Name:
Street Address:
City:
Home Phone:
School:
Parent(s)
Birth Date:
Zip Code:
Work Phone:
Teacher:
Grade:
Your child has been referred for diagnostic evaluation. This evaluation will be for educational
purposes. The information gained will be used to determine if he/she is eligible for special
education and, if so, to plan appropriate programs and services. Parents and school
personnel are involved in the evaluation process. R340.1721(1)(a).
EVALUATION TEAM (the evaluation may be conducted by the following qualified personnel) R340.1721a(3):
Psychologist
Teacher Consultant
School Social Worker
Speech/Language Teacher
General Education Teacher
Other
Descriptions of evaluation services and types of tests that may be used are listed on the back of this
form. Staff services or information regarding the tests will be explained in more detail at your request.
If it is necessary, tests and other evaluation material shall be provided in the student’s native language,
which is English unless other noted here:
Your “Procedural Safeguards Available to Parents of Children with Disabilities”, a description of
the types of special education programs and services, and a list of organizations available to you are
attached.
As part of the MET process, you are encouraged to provide current information concerning your child.
I have received information regarding the evaluation procedures, tests, records, or reports the district
proposes to use. I understand the content of this notice. I have been informed of parental rights and
due process procedures, and have received a list of special education programs, services and
organizations available to me.
I consent to the personality testing.
I consent to the above evaluation for my child.
I refuse permission for the above evaluation for my child.
______________________________
Date
___________________________________________
Signature of Parent/Guardian
R340.1721c, R341.1723a
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EXPLANATION OF EVALUATION SERVICES
School Psychologist
The school psychologist may evaluate a student in the areas of intelligence, personality, academic achievement and
perception using tests and observation. Personality testing requires specific written consent any time administered. Upon
completion of tests, parents and school personnel involved will be notified of the evaluation results.
School Social Worker
The school social worker evaluates a student’s social and behavioral adjustment. The following are often used in making this
determination: 1) family interview; 2) student conferences; 3) teacher conferences; 4) observations; 5) collection of
information and coordination of service with other agencies (if appropriate).
Teacher Consultant
A teacher consultant primarily evaluates academic achievement and may make observations in the special or regular
education settings.
Teacher of the Speech and Language Impaired
A teacher of the speech and language impaired evaluates speech and language behavior. Tests to diagnose the problem may
be given in the following areas:
Language Development:
Assessment of student’s ability to process, understand
and communicate verbal ideas.
Articulation:
Assessment of the student’s ability to speak clearly and
effectively.
Voice:
Assessment of the student’s ability to utilize appropriate
voice pitch, loudness or quality of speech.
Fluency:
Assessment of the student’s ability to speak without
excessive interruptions; repetition of sounds, words,
phrases or sentences which interfere with effective
communication.
Occupational/Physical Therapists
The Occupational Therapists’ and/or Physical /Therapists’ evaluations are done in gross, fine and perceptual motor skills and
activities of daily living.
Audiologist
The audiologist assesses the student to determine the amount of hearing loss and to determine the effects of this loss on
speech discrimination.
Medical Services Personnel
Neurologist
Pediatrician
Psychiatrist
Orthopedic Surgeon
Internist
Osteopathic Internist
Ophthalmologist
Optometrist
Otolaryngologist
The medical personnel identified above provide diagnostic information relevant to the presence or absence of a physical or
mental disorder or condition. The suspected handicapped condition will determine the medical personnel that should be
involved.
Vocational Assessment
An assessment of the student’s aptitudes, interests, personal adjustment skills, and achievements must be conducted prior to
vocational education placement.
Others: Identify and Describe
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“YOUR” COMMUNITY SCHOOLS
STUDENT SUPPORT SERVICES
XX, Director
XX, Assistant Director
Your Schools Address
Phone: x
Fax: x
GENERAL INFORMATION
“YOUR” Community Schools comprehensive Special
Education department provides additional support and
service to those students who qualify. Our staff includes
psychologists, social workers, speech therapists,
occupational therapists, physical therapists, teachers and
paraprofessionals. Specific programs of support are
developed by an Individualized Educational Planning
Team and may include classroom support, speech
therapy, social work, or other services. These services
are provided at all schools in the district. For information
regarding these services, please contact our XX office at
( ) xxx - xxxx.
Pre-primary age students with special needs are serviced
in specialized programs for xxxxxx. These programs are
housed at xxxxx. For information regarding these
programs please call xxxx at ( ) xxx - xxxx or xxxx at ( )
xxx - xxxx.
In some instances, specialized teachers and programs
better serve our students. Center programs, operated by
“YOUR” Schools, service students needing additional
special education services. “YOUR” hosts center
programs, preschool through post high school, for
students with autism. Students are enrolled in these
programs following a referral by the school district and a
complete diagnostic evaluation. For information regarding
programs for students with autism, please contact xxx at
( ) xxx - xxxx
Schools in the “YOUR” School District are listed below. All
schools offer basic and resource room support as well as all
ancillary support services. Specialized and center
programs are listed for individual buildings.
OUT OF DISTRICT CENTER PROGRAMS USED BY
“YOUR” STUDENTS
Emotionally Impaired
Specific to your area
Hearing Impaired
Specific to your area
Physically or Otherwise Health Impaired
Specific to your area
Severely Mentally Impaired
Specific to your area
Severely Multiply Impaired
Specific to your area
Trainable Mentally Impaired
Specific to your area
Visually Impaired
Specific to your area
DIAGNOSTIC AND EDUCATIONAL SERVICES
PROVIDED BY “YOUR” SCHOOLS
Specific to your area
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