Aberdeen School District 6-1

Aberdeen School District 6-1

Department of Special Services

Consent for ____Initial ____ 3-Year Evaluation Date ______

Student Name ______Birthdate ______

Address ______Chronological Age ______

Parent/Guardian ______Grade ______School ______

Telephone (Home) ______Work ______Classroom Teacher ______

Parent Input:

As per our conversation/visit on ______, it was agreed the specified evaluations listed below will be administered or previous information used to determine initial eligibility or continued eligibility for special education services.

OUR PROPOSED PLAN IS:

EVALUATION(S) REQUESTED DESCRIPTIONS POSITION

Educational/Psychological

___ Educational/Skill Based Assessment Assesses achievement in academic areas such as reading,

math, written language, general knowledge and behavior. ______

___ Intellectual/Cognitive Assessment Assesses general intellectual abilities and processing. ______

___ Behavior/Emotional Assesses emotional/behavior adjustment. ______

___ Social Assesses interpersonal relationships ______

___ Adaptive Behavior Assesses competence in the school and/or home/community. ______

___ Vocational/Transition Assesses employment, recreation & leisure, home living,

community participation &post secondary education. ______

___ Developmental Tests To determine child’s level of physical and cognitive

development. Personal, Social, Adaptive, Communication,

Cognitive and Motor Skills. ______

___ Classroom Observation ______

___ Attention/hyperactivity Assesses attention/concentration/hyperactivity/

impulsivity. ______

Speech/Language

___ Speech Assesses production of speech sounds, voice, and/or fluency. ______

___ Language Assesses the ability to understand and use language. ______

Medical/Health Related

___ Vision Assesses visual acuity and functioning. ______

___ Medical/Health History Assesses relevant health issues. ______

___ Hearing Assesses auditory acuity and functioning. ______

Autism Spectrum Disorder/PDD

___ Screening To screen for problems with social reciprocity, communication,

restricted patterns of behavior/interest and activities. ______

___ Assessment To determine if problems with social reciprocity, communication,

restricted patterns of behavior/interests and activities. ______

Sensory

___ Screen Screen sensory processors & modulation to determine if further

evaluation is needed. ______

___ Assessment Assess sensory processing and modulation. ______

Motor Development

___ Gross Motor Assesses coordination and large muscle skills. ______

___ Fine Motor/Visual Motor Assesses perceptual motor and small muscle skills, to perceive

Perception Tests what is seen, or written. ______

___ Other ______

PARENTAL CONSENT

“Consent” means that the parents have been fully informed of all information relevant to the activity for which consent is sought, in the native language, or other mode of communication; the parents understand and agree in writing to the carrying out of the activity for which consent is sought, and the consent describes that activity and lists any records which will be released and to whom; and the granting of consent by the parents is voluntary and may be revoked in writing at any time. If the parent revokes consent in writing for their child’s receipt of special education services after the child is initially provided special education and related services, the local education agency is not required to amend the child’s education records to remove any references to the child’s receipt of special education and related services because of the revocation of consent.

___ Consent is given to conduct the evaluation(s) as described.

___ Consent is denied. At the school district’s request and for reasons which I agree to, I am willing to

extend the 25 school day timeline for the completion of all my student’s

assessments to: ______(Date) ______(Initials)

______Parent’s Signature Date

Revised 3-11

Received by the District ______Initial ______