Re-Evaluation Educational Therapy Evaluation

Guardian Information Form

Your child is due for an Educational Therapy Re-Evaluation to review progress and determine whether school-based services are still needed.

Please complete the information below to help us understand your student’s needs.

Step 1 of 3

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

Educational Occupational Therapy

Educational Physical Therapy

Educational Speech-Language Therapy

Student Information

Student Name(Required)

First Last

Parent/Guardian Name(Required)

First Last

Phone(Required)

Email(Required)

Progress at Home - Educational Occupational Therapy

Have you noticed improvement in fine-motor skills or independence?(Required)

Significant improvement

Some improvement

Minimal improvement

No change

Please describe your observations.(Required)

Current Concerns - Educational Occupational Therapy

Do you still have concerns related to:(Required)

Handwriting

Dressing skills

Organization

Attention to tasks

Sensory regulation

Independence

Other

None of the above

Please describe your concerns.(Required)

School Participation - Educational Occupational Therapy

Do you believe your child continues to need occupational therapy support to participate successfully at school?(Required)

Yes

Unsure

Please explain your reasoning.(Required)

Dismissal Consideration - Educational Occupational Therapy

Based on your observations at home and school, do you believe your child’s motor and functional skills now allow them to:(Required)

Complete classroom tasks such as writing, cutting, or using school tools without specialized support

Manage materials and classroom routines independently

Participate in school activities similarly to same-age peers

Maintain appropriate posture and focus during schoolwork

Demonstrate knowledge without fine-motor or sensory barriers

None of the above

Have previous fine-motor, sensory, or functional concerns improved to a level that no longer negatively affects your child’s performance at school?(Required)

Yes

Unsure

Please describe the changes you have observed.(Required)

If some concerns remain, do you believe these can be managed through classroom supports or accommodations rather than direct occupational therapy services?(Required)

Yes

Unsure

Please explain your reasoning.(Required)

Progress at Home - Educational Physical Therapy

Have you noticed improvement in:(Required)

Walking

Balance

Stairs

Endurance

Playground participation

Overall mobility

None of the above

Please describe your observations.(Required)

Current Concerns - Educational Physical Therapy

Do you still have concerns about your child’s physical abilities at school?(Required)

School Participation

Do you believe your child continues to need educational physical therapy?(Required)

Yes

Unsure

Please explain your reasoning.(Required)

Dismissal Consideration - Educational Physical Therapy

Based on your observations at home and school, do you believe your child’s mobility and physical abilities now allow them to:(Required)

Safely move throughout the school environment (classroom, hallways, playground)

Transition between activities independently

Maintain appropriate positioning for learning tasks

Participate in classroom and school activities similarly to same-age peers

Access the school environment without physical barriers

None of the above

Have previous gross-motor, balance, strength, or mobility concerns improved to a level that no longer negatively affects your child’s performance at school?(Required)

Yes

Unsure

Please describe the changes you have observed.(Required)

If some physical concerns remain, do you believe these can be managed through educational accommodations or environmental supports rather than direct physical therapy services?(Required)

Yes

Unsure

Please explain your reasoning.(Required)

Progress at Home - Educational Speech-Language Therapy

Have you noticed improvement in your child’s communication skills?(Required)

Significant improvement

Some improvement

Minimal improvement

No change

Please describe any improvements in speech clarity, understanding language, expressing ideas, or social communication.(Required)

Current Communication Concerns - Educational Speech-Language Therapy

Do you still have concerns related to:(Required)

Speech-sound production (pronunciation)

Being understood by others

Understanding directions

Expressing thoughts clearly

Vocabulary development

Answering questions appropriately

Social communication with peers

Fluency (stuttering)

Voice concerns

Other

None of the above

Please describe your concerns.(Required)

School Participation

Do you believe your child continues to need educational speech-language therapy?(Required)

Yes

Unsure

Please explain your reasoning.(Required)

Dismissal Consideration - Educational Speech-Language Therapy

Based on your observations, do you believe your child’s communication skills now allow them to:(Required)

Be understood by teachers and peers in the classroom

Participate in classroom discussions without specialized support

Complete grade-level work that requires speaking, listening, or explaining ideas

Interact socially with peers in an age-appropriate manner

Demonstrate knowledge without communication barriers

None of the above

Have previous speech or language concerns improved to a level that no longer negatively affects your child’s performance at school?(Required)

Yes

Unsure

Please describe what changes you have observed.(Required)

If some concerns remain, do you believe these can be managed through regular classroom support rather than direct speech-language therapy?(Required)

Yes

Unsure

Please explain your reasoning.(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 IEP team to consider when reviewing your child’s continued need for services?

info@dtchuntington.org

(304) 523-1164

Re-Evaluation Educational Therapy Evaluation

Guardian Information Form

Student Information

Progress at Home - Educational Occupational Therapy

Current Concerns - Educational Occupational Therapy

School Participation - Educational Occupational Therapy

Dismissal Consideration - Educational Occupational Therapy

Progress at Home - Educational Physical Therapy

Current Concerns - Educational Physical Therapy

School Participation

Dismissal Consideration - Educational Physical Therapy

Progress at Home - Educational Speech-Language Therapy

Current Communication Concerns - Educational Speech-Language Therapy

School Participation

Dismissal Consideration - Educational Speech-Language Therapy

Additional Information