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

such as medical diagnosis, First Steps referral, recent hospitalization, outside therapy, behavior concerns, parent concerns