Request for Services (CORP) — School Year 2021-22 HDESD Request for Evaluation / Service Your Name* First Last Email* Phone*Student Name* First Last Student Date of Birth (DOB)* Month Day Year Student School District*Bend-LaPineCrook CountyCulverHarney CountyHDESD EI/ECSEJeffersonNorth CentralRedmondSistersStudent School* Is this student* EI ECSE School Age Post Secondary Does this student have a current IEP/IFSP?* Yes No IEP/IFSP UploadAccepted file types: pdf, Max. file size: 128 MB.CommentsArea(s) requesting service/evaluation:*Choose all that apply. Assistive Technology (AT) (request for service only) Augmentative Communication (Aug Com)(request for service only) Autism (ASD) Deaf/Hard of Hearing (DHH) Occupational Therapy (OT) Physical Therapy (PT) Traumatic Brain Injury (TBI)(request for service only) Vision Impaired (VI) Deaf/Blind (DB)(request for service only) DHH Required DocumentsPlease upload the hearing report. Failure to upload will delay the process. If you are unable to upload documents please email as an attachment to jan.colvin@hdesd.orgMax. file size: 50 MB.Vision Required DocumentsPlease upload the vision report. Failure to upload will delay the process. If you are unable to upload documents please email as an attachment to jan.colvin@hdesd.orgMax. file size: 50 MB.Important Additional Information Required Please upload your district's pre-referral, referral, and signed parent consent to evaluate. Failure to upload these documents will delay the process. If you are unable to upload file please email to jan.colvin@hdesd.org Drop files here or Select files Max. file size: 10 MB, Max. files: 10. PhoneThis field is for validation purposes and should be left unchanged. Δ
