Date ____________________

Learner’s Full Name ______________________________________________ DOB ________________ M / F
Parent/Guardian ___________________________________________________________________________
Address ____________________________________________ City ________________  Zip _____________
Home Phone _______________________________   Work Phone ___________________________________
Referred by _____________________________________    Position _________________________________
District _________________  Phone ___________  Current IEP? yes no Disability ______________________
Grade ________ Teacher ________________________
Date of parent contact: _______________  Method of parent contact:_________________________________

1. Are you requesting:
____ Student Consultation _____ Student Evaluation* _____ Consultation with Teacher

2. Area(s) of concern:
_____ Intellectual _____ Motor
_____ Assistive Technology _____ Functional
_____ Hearing (attach hearing screening results or previous audiogram)
_____ Vision (attach vision screening or opthamological report)
_____ Behavior Analysis _____ Health/Physical
_____ Other ______________________________________________________________________________

3. Are there any scheduling concerns for this child? (attends part days, alternate dates, etc.)

4. Reason for request (include interventions tried to date that address the area(s) of concern, inadequate progress on IEP goal, developmental skill level, etc.):
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

*All requests for evaluations require parent consent.
  SEND A COPY of this request to your BRIC Coordinator.
  For BRIC Office Use Only

Date received ______________ Coordinator___________________________________________________

Consultant ______________________________ Director ________________________________________

Date of Consultation ____________________________

Revised 8/21/07