IE Evaluation Request Form
Submit your request for an Independent Educational Evaluation (IE). Please provide detailed information to support your request.
Student Full Name
*
First Name
Last Name
Student Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student Grade Level
*
Please Select
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Requester Full Name
*
First Name
Last Name
Relationship to Student
*
Please Select
Parent/Guardian
Teacher
School Administrator
Other
Requester Email Address
*
example@example.com
Requester Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Evaluation Request
*
Areas of Evaluation Requested (select all that apply)
*
Cognitive/Intellectual Ability
Academic Achievement
Speech and Language
Social/Emotional/Behavioral
Occupational Therapy
Physical Therapy
Other
Has the student previously received an evaluation?
*
Yes
No
If yes, please provide details of previous evaluations (type, date, findings)
Please rate your level of concern for the following areas:
*
Rows
Not Concerned
Somewhat Concerned
Very Concerned
Academic Performance
1
2
3
Attention/Focus
4
5
6
Behavior
7
8
9
Communication Skills
10
11
12
Social Skills
13
14
15
Additional Comments or Information (optional)
Submit Request
Should be Empty: