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Parent/Guardian Name *

Preferred contact method

Student Name

Type of Evaluation Needed (check all that apply) Psychoeducational Speech / Language (SLP) Occupational Therapy (OT) Physical Therapy (PT) Adaptive Physical Education (APE) Not Sure

Reason for IEE Request

(Example: disagreement with school evaluation, need second opinion, etc.)

School District Status Select an option... School district already agreed to fund IEE District denied evaluation Parent requesting independent evaluation Not sure

Previous Evaluations School district evaluation completed Private evaluation completed No previous evaluations

Urgency Select an option... Urgent (within 2 weeks) Standard (30 days) Just exploring options

Additional Notes

How did you hear about us? Select an option... Google Search School District Parent Referral Attorney Advocate Other