2024-2025 Evaluation & Related Services Referral Form

Once submitted, this form will automatically create a ticket that will be reviewed by the Operations Team. You will receive notification when an evaluator or therapist has been assigned. If you need to request more than one area of therapy or evaluation for the same student, please submit one form per area. For example, a student who requires an OT evaluation and a psychological evaluation would need to have two forms submitted.

Please DO NOT submit pre-approved students using this form. Students should be submitted via form when they are enrolled.
This form should be used for referrals, NOT for planning meetings.

Email*

Please enter the name of the person submitting this request.

Student ID*

School Name*

Zip code of Student

Priority

Type of Request*

Please select one.

Related Services Therapy Type

If you are filling out this form for a related services therapy referral (this includes both new referrals and changes in status), please indicate the type of therapy requested below. You will be prompted to fill out additional fields after selecting the type of service.

If you are filling this form out because a service has been removed from the IEP, remember to enter "0" for the number of monthly minutes.

If you are filling out this form because a service has been removed from the IEP or a student withdrew from school, remember to select "Student Withdrew" or "Service Removed from IEP" when entering the therapy type.

DO NOT fill out this field if you are making an evaluation referral or ESY referral.

ESY Area for Related Services

If you are filling this form for an ESY referral , please indicate the therapy type below. You will be prompted to fill out additional details after selecting the type of service.

Please include the following information in the "Details" field: setting, related service, minutes, frequency, and duration for ESY

Example: Virtual OT, 8 sessions at 30 minutes each, weekly sessions between June 1 and August 1 for ESY

Ticket name*

Please use the following naming conventions for referrals: Type of Request_Area_School Acronym_Student ID_Vendor Preference_Evaluator Preference_SY

Example for Eval Request: Evaluation_Psychological_MyCA_122334_Demo Company_Evelyn Exceptional

Example for Therapy Request: Therapy_OT_MyCA_122334_Demo Company_Evelyn Exceptional

Ticket description*

Please include any additional information relevant to this referral submission. Please do not add email addresses to this text field; school stakeholders are automatically added to tickets according to the lists provided by schools earlier this semester.