Initial Educational Therapy Evaluation

Guardian Information Form

Your student has been referred to consider an Initial Educational Therapy Evaluation to determine whether school-based services are educationally necessary under WV Policy 2419.

Please complete the information below to help us understand your student’s strengths and educational needs. Completion of this form does not replace required consent procedures.

Step 1 of 6

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Please select the therapy discipline(s) for which this evaluation is being considered.(Required)

Educational Occupational Therapy

Educational Physical Therapy

Educational Speech-Language Therapy

Student Information

Student Name(Required)

First Last

Date of Birth(Required)

Grade(Required)

School(Required)

Parent/Guardian Name(Required)

First Last

Phone(Required)

Email(Required)

Preferred Method of Contact(Required)

Phone

Medical Provider Information

Current Pediatrician/Primary Care Provider(Required)

Practice Name (if known)

Date of Last Well Child Visit(Required)

Please note that in order for us to receive a valid therapy prescription, the student must have been seen by their physician within the last year.

Has your child had any recent medical updates, diagnoses, or changes since the last well visit that may impact school performance?(Required)

Yes

Please describe the changes since the last well visit.(Required)

Concerns Related to Educational Occupational Therapy

School-based occupational therapy services are provided when a student’s motor, sensory, or functional performance challenges adversely impact their ability to access, participate in, or make progress in the general education curriculum. Educational occupational therapy focuses on skills necessary for school performance, including fine-motor development, visual-motor integration, classroom tool use, self-care tasks within the school environment, sensory regulation, and independence with academic and daily classroom routines.

What concerns led to this Educational Occupational Therapy Referral?(Required)

Does your child have difficulty with any of the following at school?(Required)

Handwriting

Holding a pencil/crayon

Cutting with scissors

Managing buttons/zippers

Opening containers/lunch items

Staying organized

Following multi-step directions

Tolerating classroom noises/textures

Other

Please provide any additional details about your child's difficulties.(Required)

How do these concerns affect your child’s participation, independence, or success at school?(Required)

Strengths Related to Educational Occupational Therapy

What are your child’s occupational strengths?(Required)

What occupational activities does your child enjoy?(Required)

Occupational Medical Considerations Related to School Performance

Are there any medical conditions, diagnoses, or concerns that may impact your child’s school performance?(Required)

Is your child currently taking any medication that affects attention, behavior, or physical functioning at school?(Required)

Yes

Please provide more detail about your child's medication.(Required)

Concerns Related to Educational Physical Therapy

School-based physical therapy services are provided when a student’s gross motor, mobility, postural control, or physical access needs adversely impact their ability to access, participate in, or make progress in the general education curriculum. Educational physical therapy supports safe and functional mobility within the school setting, including classroom access, transitions, participation in school routines, positioning for learning, and engagement in school-related activities.

What concerns led to this Educational Physical Therapy Referral?(Required)

Does your child have difficulty with any of the following at school?(Required)

Select all that apply.

Walking long distances

Navigating stairs

Balance

Running or jumping

Playground participation

Keeping up with peers

Sitting upright for extended periods

Getting on/off the floor

Carrying materials

Other

Please provide any additional details about your child's difficulties.(Required)

How do these concerns affect your child’s participation, independence, or success at school?(Required)

Strengths Related to Educational Physical Therapy

What are your child's physical strengths?(Required)

What physical activities does your child enjoy?(Required)

Equipment & Mobility

Does your child use any of the following?(Required)

Select all that apply.

Orthotics

Walker

Wheelchair

Adaptive seating

Braces

None

Other

Please provide additional details regarding your child's equipment and mobility.(Required)

Physical Medical Considerations Related to School Performance

Are there any medical conditions, diagnoses, or concerns that impact your child’s strength, balance, mobility, or endurance?(Required)

Has your child experienced any recent injuries or surgeries?(Required)

Yes

Please explain the injury or surgery.(Required)

Concerns Related to Educational Speech Therapy

School-based speech-language therapy services are provided when a communication disorder adversely impacts a student’s ability to access, participate in, or make progress in the general education curriculum.

What concerns led to this referral?(Required)

Does your child have difficulty with any of the following at school?(Required)

Select all that apply.

Pronouncing speech sounds clearly enough to be understood in the classroom

Being understood by unfamiliar listeners (teachers, peers)

Understanding grade-level vocabulary

Following multi-step directions

Answering questions in complete sentences

Organizing thoughts to tell a story or explain ideas

Retelling information from stories or lessons

Participating in group discussions

Staying on topic during conversations

Social communication (turn-taking, interpreting social cues)

Fluency (stuttering that impacts participation)

Voice concerns affecting classroom communication

Other

How do these concerns affect your child’s participation, independence, or success at school?(Required)

Strengths Related to Educational Speech-Language Therapy

What are your child's communication strengths?(Required)

In what situations does your child communicate most successfully (homework, one-on-one conversations, small groups, etc.)?(Required)

Speech Medical/Hearing Considerations Related to School Performance

Are there any medical conditions, diagnoses, or concerns that impact your child’s communication at school?(Required)

Has your child had a recent hearing screening?(Required)

Yes

Unsure

Please describe any concerns related to the hearing screening.(Required)

Is your child currently taking any medication that affects attention, behavior, or communication during school activities?(Required)

Yes

Please provide more detail about your child's medication.(Required)

Previous Services

Has your child previously received any of the following services?(Required)

Select all that apply.

Speech-Language Therapy

Occupational Therapy

Physical Therapy

Birth to Three

Private therapy

No prior services

Please describe when and whether services were school-based or medical.(Required)

Additional Information

What is the preferred time of day for the IEP meeting to review the completed evaluation?(Required)

Morning (8:00 AM – 11:00 AM)

Midday (11:00 AM – 1:00 PM)

Early Afternoon (1:00 PM – 3:00 PM)

Other (within school hours)

If other, please provide your availability.(Required)

Which days are preferred for the IEP meeting to review the completed evaluation?(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Is there anything else you would like the evaluation team to know?

info@dtchuntington.org

(304) 523-1164

Initial Educational Therapy Evaluation

Guardian Information Form

Student Information

Medical Provider Information

Equipment & Mobility

Previous Services

Additional Information