Educational Assessment and Intervention Services
973-655-4247
Description of Services and Fee Schedule
The purpose of Educational Assessment and Intervention Services (EAIS) is to provide high quality
educational evaluations and academic interventions for students from the community and to provide
practical experiences for graduate students of Montclair State University’s Special Education, Learning
Disabilities, and School Psychology programs. EAIS is dedicated to the implementation of evidence-based
practices so that the best possible educational outcomes are achieved for students. Services are provided
by graduate students who are supervised by faculty members at MSU.
Please fill out the enclosed application. Feel free to submit any additional information that will help us
understand the issues of concern (e.g., previous evaluation results, IEPs, report cards, teacher reports,
etc.). You will be sent a schedule of times to meet with us for the purposes of obtaining additional
information, conducting the evaluation, and interpreting the results. You will receive a comprehensive
written report with recommendations.
Our evaluations will be conducted on Tuesday evenings from 5:30-7:30 and Saturday mornings from 9:001:00. We ask that you be prepared to attend sessions on either Tuesday or Saturday. Tutoring supports are
provided on Saturday mornings from 9:00-1:00.
Team Educational and Psychological Evaluation
$400.00
An individualized evaluation of a child’s academic, behavioral, and social emotional strengths
and needs is used to develop a plan for improving a student’s skills and success in school.
Educational Evaluation
$200.00
An individualized evaluation of a child’s academic strengths and needs is used to develop a
plan for improving a student’s skills and success in school.
Academic Tutoring
High quality, research-based interventions and strategies are implemented to build on your
child’s strengths and improve areas of need.
MSU EAIS Application
see fee
schedule
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Educational Assessment and Intervention Services
973-655-4247
APPLICATION
Please complete this and send it by mail or fax to:
Educational Assessment and Intervention Services
Montclair State University
1 Normal Avenue - University Hall 3124
Upper Montclair, NJ 07043
Fax: 973. 655.4048 Attn: Tina Seaboch
seabocht@mail.montclair.edu
All information will be treated confidentially. No schools, individuals or agencies will be contacted
without your specific written permission.
Today’s Date _______________________
Client’s name _____________________________________ Nickname ___________________________
Date of Birth _______________________ Age _______ Sex (M/F) ______
Parent/Guardian name(s) _____________________________________________________________________
Address ______________________________________________________________________________
City, STATE _______________________ Zip Code ________ Years at this address ________________
Phone No. _________________________ Business Phone No. __________________________________
Cell Phone No. ________________________ Email Address(es) ________________________________
Language (s) spoken at home _____________________________________________________________
If parents of applicant are divorced, please indicate legal status of custody __________________________
_____________________________________________________________________________________
School __________________________________________________ Grade _______
School Address ________________________________________________________________________
Teacher _______________________ Counselor ______________________________________________
Child Study Team Member (if in special education) ____________________________________________
MSU EAIS Application
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Educational Assessment and Intervention Services
973-655-4247
Previous School(s)
Name of School
Grades and Dates Attended
Reason for Leaving
Referred by _______________________________ Relationship to client __________________________
Is your child currently being tested?
Yes
No
If yes, please specify. ___________________________________________________________________
What concerns brought you to us? (Use back of sheet, if necessary) ____________________________
____________________________________________________________________________________
Why are you having your child evaluated?
Obtain information about academic strengths and needs
Obtain information about behavioral and/or social emotional strengths and needs
Develop instructional plan/recommendations for school
Provide information for special education eligibility
Provide information for 504 eligibility
Other. Please explain: _______________________________________________________________
_____________________________________________________________________________________
MSU EAIS Application
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Educational Assessment and Intervention Services
973-655-4247
What service are you requesting?
Team Educational and Psychological Evaluation
Educational Evaluation
Academic Tutoring
Educational Evaluation and Academic Tutoring
Team Educational and Psychological Evaluation and Academic Tutoring
Describe anything special or different about client’s development (i.e., physical, academic, social,
emotional, language). ___________________________________________________________________
_____________________________________________________________________________________
Have any of the following tests been conducted? If yes, please complete.
By whom?
When?
Results
Hearing
Psychological
Neurological
Educational
Speech and
Language
Other
Is the individual seeing any of the above or other professionals now? If yes, list and state reasons.
_____________________________________________________________________________________
____________________________________________________________________________________________
MSU EAIS Application
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Educational Assessment and Intervention Services
973-655-4247
Please list any additional important information about the student here.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________
Signature
Relationship to Client: _______________________
MSU EAIS Application
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Educational Assessment and Intervention Services
973-655-4247
Educational Assessment and Intervention Services is an integral part of the teaching and research
programs of Montclair State University. All services provided by EAIS are performed by graduate students
working under the supervision of qualified faculty and clinical associates. Evaluations and conferences with
parents are observed by students through a secure computer system or recorded on video or audio tape for
future discussions by groups of students and their instructors at the University. In view of the foregoing,
EAIS can accept for service only those clients who are willing to cooperate with the educational and
research activities of EAIS, as indicated above. Applicants may be assured that such activities will in no
way interfere with the quality of services provided.
……………………………………………………………………………………………………………………………
I have read the above statement and agree:
a) that services may be rendered to me or my child by both graduate students, and clinical
associates.
b) that sessions in which my child and/or I participate may be viewed by students at the
EAIS facilities or may be recorded on audio or video tape and used in connection with
the teaching and research programs of EAIS, including presentations at professional
meetings.
____________________________
Signature
(Parent /Guardian must sign if applicant is a minor)
Date ______________________
MSU EAIS Application
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