Service Request | Second Mile Therapy

Your Name *

First

Last

Email *

School District

Student Name *

First

Last

Student Birth Date *

Requested Completion Date *

How old is the student? *

The child is not yet school age
The child is in PreK
The child is school age

Do we need to contact the parents/guardians to arrange a time for the child to be brought in for an evaluation? *

Yes, the therapist needs to arrange a time with the parents
No, the school has already arranged a time for the screening/evaluation/therapy

What is the best contact # for the parents/guardians? *

Teacher *

Parent/Guardian's Names *

When is this PreK student at school? *

AM Class
PM Class
All Day

Discipline Requested *

Speech-Language Therapy
Occupational Therapy
Physical Therapy

Services Requested *

When is the meeting scheduled? *

Date

Time

What is the purpose of this meeting? *

Review of existing data (RED)
Develop an initial IEP/revise annual IEP
Determination of Eligibility
Parent/IEP team conference

Date Parent Signature Was Obtained *

Does the child have a current IEP *

No
Yes

Has the student been evaluated or received services in the past? *

No
Yes

Concerns with Communication Include *

Occupational Therapy Concerns *

Fine Motor skills
Visual Perceptual Skills
Sensory Integration

Physical Therapy Concerns *

Balance
Reduced Coordination
Reduced Strength
Reduced Endurance

Screen for Gross Motor Red Flags *

Yes
No

Gross motor and fine motor skills are closely tied together. If a child has trouble with fine motor skills it is prudent to rule out any gross motor issues as well.

Additional Information we need to know