Evaluation Request Form Early Learning Center and Lower School

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~Student~ Page 1 of 12

How did you hear about us?

How did you hear about Perkins Diagnostic Evaluations?

If other, please be specific:

Word of mouth via?

Student Information

First Name

Last Name

Birthdate

Gender

Student Address

Street Address

City

State

Zip/Postal Code

If you have applied to Perkins within the last 6 months, please contact our office before submitting any documents other than this application.

While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Additional Contacts~ Page 2 of 12

Parent or Guardian

Relation to Student

First Name

Last Name

must be unique for each contact

Phone Number

ex: ###-###-####

This is the person completing this form

Additional Parent or Guardian

checkbox

Mark this checkbox to add an additional Parent or Guardian

Additional Parent/Guardian

Relation to Student

First Name

Last Name

must be unique for each contact

Phone Number

ex: ###-###-####

This is the person completing this form

School District Contact/Other Contact

Relation to Student

District/Organization

Title

First Name

Last Name

must be unique for each contact

Phone Number

ex: ###-###-####

This is the person completing this form

While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Medical Information~ Page 3 of 12

Birth History

Full Term?

If No, gestational age

Complications during or following birth?

If yes, please describe

Did the child spend time in the NICU after birth?

If yes, how long?

Diagnosis

Additional Medical and Health Conditions

Check all that apply based on the medical reports

AllergiesCerebral palsyDeaf or hearing impairedEndocrine disorderFeeding problemsHeart disorderMedical device dependent (i.e., g-tube, oxygen, etc.)Orthopedic impairmentRespiratory problemsSeizure disorder / infantile spasmsNone

Please describe the student's Allergies (be specific)

Please describe the student's hearing

Please describe the student's medical devices:

Other medical or health conditions:

Physical Exam and Hospitalizations

Date of last physical examination:

Height:

Weight:

Hospitalizations / Surgeries (list eye surgeries in vision section which follows)

Seizures

Does the child experience seizures?

Frequency/Duration

Type

Intensity

While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Medical Information Continued~ Page 4 of 12

Is the student currently taking medication?

Medications (*To add another medical condition use the Add Another Medication link below)

Medication

Reason for Use

Vision Information

Primary visual diagnosis as determined by medical reports:

Blind

Light Perception

Visual Acuity

Visual Acuity Right Eye

Visual Acuity Left Eye

Visual Acuity Both Eyes

Cortical/Cerebral Visual Impairment (CVI)

If known, what is the student's Cortical/Cerebral Visual Impairment (CVI) Phase and Range?

If Cortical/Cerebral Visual Impairment (CVI) is suspected but not diagnosed, please describe?

Does the child use (check all that apply)

Glasses (prescription and/or sunglasses)ProsthesisContact lensesOther low vision aids (magnifier, CCTV, telescopes)None

Please list "other" visual aids:

Date of last eye exam

Ophthalmologist's name

Visual behaviors (check all that apply)

Eccentric viewing (head tilt)Eye pressingGaze aversionHead shakingInconsistent visual performanceLight gazing (including finger flicking)Photophobic (light sensitive)Responds to objects only if held closeNoneOther (please describe below):

Please describe "Other" visual behaviors

Eye surgeries (please list with date)

Hearing Information

Hearing test results:

If Not Within Normal Limits, please indicate type of loss:

Degree of hearing loss:

List prescribed aids (i.e., hearing aids, cochlear implants, FM unit):

While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Communication Information~ Page 5 of 12

Primary language used by student

Please describe how your child communicates

Receptive language (how the student understands language) (check all that apply)

Augmentative communication deviceBody languageFacial ExpressionsGesturesMayer-Johnson picturesObjectsPhotographs / PicturesSign languageSpeechTangible Symbols

Expressive methods used (how the student communicates wants, needs, and ideas)

Augmentative communication deviceBody languageFacial expressionsGesturesMayer-Johnson picturesObjectsPhotographsSign languageSoundsSpeechTangible Symbols

Length of utterances expressed

Single wordsShort phrasesSentences

Speech Intelligibility

Easily understood by othersUnderstood with some difficultyNot understandable

Follows directions

Does not follow directionsUnderstands functional directions1-Step (ex: 'clap your hands')2-Step (ex: 'clap your hands, then stomp your feet')Multiple-Step/within functional limits

Pragmatic language (use of language to interact with others):

Initiates conversationMaintains topic during a conversationMakes eye contact / turns toward listenerSays "hello" and "goodbye"Uses appropriate space boundariesWaits her/her turn

While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Social-Emotional / Behavior Information~ Page 6 of 12

Are there social/emotional concerns?

If yes, please describe social/emotional concerns:

Does the child demonstrate any behavioral challenges (for example, tantrums, head banging, aggressive behaviors, difficulties with transitions, difficulties during bedtime or mealtime routines)? Please be as specific as possible.

How frequent are any behavioral challenges, and how difficult are they for you to manage?

Is there a written behavior plan?

Are there any specific sleep problems?

Are there specific events / conditions that cause the child to become upset?

How does the child respond to unfamiliar settings and people?

What helps to calm the child when he/she is upset?

What are the child's most preferred activities? What does he/she typically do during free time?

How does the child interact with you and other adults?

How does the child interact with any siblings and/or other children?

While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Mobility Information~ Page 7 of 12

Please check all that apply

AmbulatoryAlternative caneLong caneTravels stairsWalkerWheelchair

Does the child use any vision while moving?

Does the child have any motor limitations?

If yes, please describe any motor limitations:

Does the child have physical or sensory limitations which impact hand use?

How does the child move independently?

What types of environments (such as home, school, relatives' homes) is the child exposed to?

What motivates the child to move?

Do you have specific safety concerns?

Any additional mobility information:

While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Daily Living Skills~ Page 8 of 12

Toileting:

Toileting

Toilet trained (during the day)Toilet trained (during the night)Schedule trainedIndicates need to be changedNeeds minor assistanceNeeds total assistance

Comments (include types of toilet seats or special equipment):

Food Eating / Diet /Mealtime

Eating

Eats independently (no adaptive equipment)Eats independently (may require adaptive equipment)Requires intermittent assistance and/or verbal promptsRequires significant assistance for safety and/or nutritionFood allergies (please list below):

Please list all food allergies:

Diet

RegularFed by g-tubeTherapeutic (please specify below):

Therapeutic diet specifications:

Food consistency

General diet, no modifications	Puree
Mashable	Ground
Soft diet (ex: cooked vegetables/fruit)	Nutritional drink (ex: PediaSure)

Liquid consistency

Thin liquids (water, milk, juice, etc., no modifications)	Nectar thick
Honey thick	Pudding / spoon thick

Does the child use special adaptive mealtime equipment?

Special adaptive mealtime equipment used by the child:

What type of mealtime seating does the child use?

Booster	Highchair
Rifton	TrippTrapp
Regular chair	Other (please specify below):

Please describe other mealtime seating used by the child:

Does the student eat meals in the school cafeteria?

Does the student have any notable preferences for taste or textures of foods (ex: crunchy, spicy, puree, etc.)?

If yes, please elaborate preferences for taste or textures of foods:

Has the student had a swallow study in the past?

If yes, please list the date of the most recent swallow study:

Comments (please add any additional food/mealtime information not captured above such as special equipment, adaptations, etc.)

Dressing

Dressing

IndependentNeeds some assistanceNeeds total assistance

Adaptive equipment child uses:

Additional Information:

While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Additional Student Information~ Page 9 of 12

Sensory Motor Integration

Does the student have trouble sitting & paying attention to tasks?

Does the student become upset by loud noises?

Does the student become over stimulated in busy environments?

Does the student become upset when they are dirty or messy?

Does the student dislike having his/her hair or teeth brushed?

Is the student sensitive to certain types of clothing (tags, etc.)?

Does the student avoid eating certain tastes or textures?

Does the student like swinging and rocking?

Is the student constantly moving or in motion?

Does the student like hugs, crashing on the floor, deep pressure?

Is the student overly sensitive to touch?

Is the student unaware of touch?

Educational Information

Current classroom placement

Fully includedSubstantially separate classroomHome-based servicesEarly interventionResource roomPrivate schoolOther (please describe below):

If you selected "Other" above, please describe

Pre-Braille / Compensatory Skills (please complete for children 6 and under)

Does the child identify common objects? How does the child explore them? Using his/her mouth, one or two hands?

Does the child recognize voices and familiar environmental sounds?

Does the child enjoy listening to others read stories or rhymes?

Does the child enjoy listening to audio recordings?

Does the child have a favorite book?

Does the child hold books and turn its pages?

Does the child explore texture books?

Does the child explore a variety of textures (smooth, rough, bumpy, wet, scratchy)? If so, does he/she exhibit a preference or aversion to certain textures?

Has the child been exposed to braille and if so, does he/she touch braille in exploration?

Does the student use a brailler?

Please answer the following questions if the child is 5 and older:

At approximately what grade level is the student working in reading?

At approximately what grade level is the student working in math?

At approximately what grade level is the student working in spelling?

At approximately what grade level is the student working in other areas?

If the student is functioning below kindergarten level, what is the student's estimated developmental level?

Does the student work primarily with materials in

Does the student identify

ShapesColorsObjectsPicturesPrint lettersBraille letters

Does the student have computer skills

In what academic areas does the student show the most success?

What academic areas are the most challenging?

While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Additional Student Information~ Page 10 of 12

Support Services

If the child is receiving vision services, who provides them? (Please check all that apply and indicate hours per day/week/month.)

Certified / Licensed TVI:Orientation & Mobility Specialist:Deaf / Blind Specialist:Other (please explain below):

Certified / Licensed TVI hours per day/week/month:

Orientation & Mobility Specialist hours per day/week/month:

Dead / Blind Specialist hours per day/week/month:

If you selected "Other" above, please describe:

"Other" hours per day/week/month:

Does the child receive additional services? (Check all that apply and indicate hours per date / week / month.)

Individual AideOccupational TherapyOrientation and MobilitySpeech and Language TherapyPhysical TherapyAdaptive Physical EducationPsychological ServicesComputer InstructionMusic

Individual Aide hours per day/week/month:

Occupational Therapy hours per day/week/month:

Orientation and Mobility hours per day/week/month:

Speech and Language Therapy hours per day/week/month:

Physical Therapy hours per day/week/month:

Adaptive Physical Education hours per day/week/month:

Psychological Services hours per day/week/month:

Computer Instruction hours per day/week/month:

Music hours per day/week/month:

Support Services Additional Information:

Has this child been affiliated with any Perkins-related services (for example, Infant/Toddler Program, Outreach, New England Center for Deaf Blind)?

If Yes, please describe

While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~Evaluation Questions and Concerns~ Page 11 of 12

Areas you are interested in having your student evaluated in (check all that apply)

Psychological	Educational
Speech and Language	Occupational Therapy
Physical Therapy	Orientation and Mobility
Cortical/Cerebral Visual Impairment (CVI)

Psychological Evaluations

Psychological evaluations at Perkins are conducted by school psychologists. They include a set of procedures to obtain information about a student’s cognition, social-emotional development and adjustment, and adaptive behavior. Cognitive functioning refers to skills such as verbal reasoning and concept development, problem solving/reasoning, attention, and memory. Social-emotional development and adjustment includes social skills, temperament, coping skills, and emotional/behavioral regulation. Adaptive behavior refers to a student’s level of functioning in activities of daily living.

Assessment procedures may include standardized tests, rating scales, developmental assessment, informal assessment activities/observations, and interviews. Assessment procedures are determined on an individual basis taking into consideration the student’s abilities and the referral questions and concerns.

What are your specific psychological evaluation questions and concerns?

Educational Evaluations

An educational evaluation at Perkins is conducted by a teacher of students with visual impairment (TVI) or deafblind teachers. The evaluation includes planned activities to obtain information about the student’s educational achievement in areas such as concept development, compensatory skills (taking into consideration the expanded core curriculum), literacy and math development, learning strengths, and areas of need. Evaluation activities and procedures are individually developed for each student based on their developmental presentation and submitted evaluation questions and concerns. Assessment procedures may include standardized tests, rating scales, developmental assessments, informal assessment activities/observations, and interviews. Assessment may be conducted in braille or large print or with alternative methods of communication such as Total Communication, as appropriate for each individual student. Based on evaluation findings, student-specific recommendations are made to help with educational programming and to promote the student’s educational advancement.

What are your specific educational evaluation questions and concerns?

Speech and Language Evaluations

Speech-language pathologists provide assessment in the areas of speech production (i.e., articulation, voice, and fluency), receptive and expressive language, and pragmatic communication (i.e., social use of language). Additionally, an alternative and augmentative communication (AAC) screening and/or an observation of a student’s feeding skills can be provided. Referrals will be made for more comprehensive AAC and feeding evaluations if needed.

Assessment procedures may include standardized tests, informal assessment activities/observations, and interviews. Assessment procedures are determined on an individual basis, taking into consideration the student’s abilities and the referral questions and concerns

What are your specific concerns about the student's speech, language or use of alternative and augmentative communication? Do you have concerns about this student’s ability to communicate socially? Are there questions or concerns regarding the student's ability to chew and swallow? Please explain?

Occupational Therapy Evaluations

At Perkins, occupational therapy evaluations assess various areas of a student’s development as they relate to participation in daily routines and educational activities. These assessments take a holistic approach with a specific emphasis on the unique needs of students with visual impairment and/or deafblindness. Based on the individual needs of each student, assessment areas may include: cognitive-perceptual skills; sensory functions; gross, fine, and visual motor skills; executive functioning; classroom participation; and self-care/independent living skills. Cognitive-perceptual skills refer to the thinking processes of receiving, interpreting, and organizing stimuli to determine a response. Sensory functions involve use of vision, hearing, touch, smell, taste, vestibular (i.e., movement and balance information received from receptors in the inner ear), and proprioception (i.e., body position information received from receptors in the joints and muscles). An occupational therapist evaluates a student’s ability to process input from all of these sensory systems in order to maintain a calm, regulated, and alert state for learning and participation in activities. Executive functioning involves mental skills such as memory, flexible thinking, and self-control. Based on evaluation findings, student-specific recommendations are made to maximize independence. In addition, the occupational therapist may make recommendations regarding modifications to materials, equipment, and the environment to further maximize independence.

Assessment procedures may include record review, standardized tests, rating scales/questionnaires, informal assessment activities/observations, and interviews. Assessment procedures are determined on an individual basis taking into consideration the student’s abilities and the referral questions and concerns.

What are your specific occupational therapy evaluation questions and concerns?

Physical Therapy Evaluations

The purpose of a school-based physical therapy evaluation is to identify a student’s motor development strengths and needs, particularly in regards to their ability to participate in meaningful school activities and routines, which aim to prepare students for further education, employment, and independent living, with or without assistance. Assessment areas may include gross motor, neuromuscular (i.e., muscle tone, balance, sensorimotor, motor planning), and musculoskeletal (i.e., muscle strength, range of motion, posture, gait) skills, as well as use of adaptive devices and equipment. Assessment procedures are determined on an individual basis, taking into consideration the student’s abilities and the referral questions and concerns.

Assessment procedures may include record review, use of formal assessment tools, informal assessment activities/observations, and interviews. Based on the evaluation results, student-specific recommendations are made to maximize participation and independence in accessing the student’s curriculum.

What are your specific physical therapy evaluation questions and concerns?

Orientation and Mobility Evaluations

An orientation and mobility (O&M) evaluation seeks to describe a student’s current performance in travel skills in order to provide recommendations regarding O&M instruction. The evaluation process includes record review, assessment activities/observations, and interview.

O&M is taught by a certified orientation and mobility specialist (COMS). A COMS teaches independent travel skills to people who are blind or visually impaired. Some areas of focus include, but are not limited to: white cane skills; protective techniques for moving without a cane; learning routes of travel to access different places in your home, school, and community; use of public transportation; and recovery techniques if one becomes lost. One does not need to be ambulatory to receive orientation and mobility services, but one should be able to move safely at an age-appropriate level with some degree of independence to benefit from services (for example, follow a voice guide or verbal directions).

The O&M curriculum is presented in a developmentally appropriate way, with the emphasis of instruction on the student’s current capacity and potential for independence. However, not all students will become independent travelers in their future. The goal is to help each student work towards the highest level of independence that they can safely attain.

What are your specific concerns about the student’s ability to travel?

Cortical/Cerebral Visual Impairment (CVI)

What are your specific Cortical/Cerebral Visual Impairment (CVI) screening questions and concerns?

Upon completion of this form, you will receive an email with a link to complete a short Educational Assessment specific to Cortical/Cerebral Visual Impairment (CVI).

Please list any additional questions you want the evaluators to consider for the evaluation and your

goals or purpose for the evaluation.

While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

~File Uploads~ Final Page!

If you have applied to Perkins within the last 6 months, please contact our office before submitting any documents other than this application.

File Upload

Please upload all available educational, clinical and medical reports. Any additional reports can be included as "Other File".

Refer to the Required Paperwork Checklist for all necessary application materials.

Audiological

Behavioral Support Plan

Current IEP/ISP

Development or Psychological Report

Educational

Functional Behavioral Assessment (FBA)

Functional Vision Assessment

Learning Media Assessment

Low Vision

Neurological Report

Occupational Therapy

Ophthamological

Orientation and Mobility

Physical Therapy

Progress Report

Speech and Language

Social Service

Swallow Study

Teacher of the Visually Impaired

Other File

Submit evaluation materials here or by mail, email or fax.

The following file types are accepted:

.doc (Older Microsoft Word format)
.docx (Current Microsoft Word format)
.xls (Older Microsoft Excel format)
.xlsx (Current Microsoft Excel format)
.ppt (Older Microsoft Powerpoint format)
.pptx (Current Microsoft Powerpoint format)
.pdf (Adobe PDF)
.odt (Open Office word processor document)
.ods (Open Office spreadsheet document)
.odp (Open Office presentation document)
.pages (Apple Productivity Pages document)
.keynote (Apple Productivity Keynote document)
.numbers (Apple Productivity Numbers document)

Mail - Evaluations Department, Perkins School for the Blind, 175 North Beacon St.

Watertown, MA 02472

Email - evaluations@perkins.org

Fax - (617) 972-7715

Image Upload

Image File

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.bmp (Bitmap)
.jpg (JPEG)
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.tif (Tagged Image Format)

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While filling out this form, if you have any questions please contact us at (617) 972-7573 or evaluations@perkins.org

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