Request for Psychological Evaluation Gifted by Kj24Q1

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									                               WESTMORELAND INTERMEDIATE UNIT
                              102 Equity Drive  Greensburg, PA 15601

               NON-PUBLIC SCHOOL SERVICES – REQUEST FOR GIFTED EVALUATION

Date of Request:________________________________              Date Received at WIU: _______________________
Student Name: _________________________________               Sex: ________________ Birth Date: ____________
Student Address:________________________________              Home telephone #: _________________________
                ________________________________              District of Residence:________________________
School Attending: _______________________________             Grade: ____________________________________
School Telephone #: _____________________________
Father’s Name: _________________________________              Mother’s Name: ____________________________
Father’s Address (if different than student):                 Mother’s Address (if different than student):
_____________________________________________                 __________________________________________
_____________________________________________                 __________________________________________
Home Phone (Father):___________________________               Home Phone (Mother):_______________________
Work/Cell Phone (Father):________________________             Work/Cell Phone (Mother):___________________

Student Referred by: ____________________________             Position/Telephone #: _______________________

Reason for Referral: Please describe the specific behaviors of the student in the academic and/or social-emotional-
behavioral areas that have prompted this referral.
__________________________________________________________________________________________________
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Other Referral Information:

 Have guidance services been provided for this student?         ____ Yes ____ No
  If yes, please explain _______________________________________________________________________________
  ________________________________________________________________________________________________

 Is consultation with the psychologist desired?                 ____ Yes ____ No
  If yes, by __________________________________________ (indicate teachers, counselor, parent, etc…)

 Are any other agencies involved with this student? ______________________________________________________
  ________________________________________________________________________________________________
  ________________________________________________________________________________________________

 Please list specific questions you would like answered as a result of this referral. ______________________________
  ________________________________________________________________________________________________
  ________________________________________________________________________________________________
  ________________________________________________________________________________________________
  ________________________________________________________________________________________________



                                                                               Request for Gifted Evaluation Form 1
School Information
 Was the student ever retained? ____Yes               _____No     (if yes, give year and grade) ___________________________

 What is the student’s attendance pattern? _____________________________________________________________

 Was there a previous psychological evaluation? ____Yes ____No
  If yes, Date of Psychological evaluation _____________________ Completed by:______________________________
  Summary:_______________________________________________________________________________________

 Has the student ever received an IEP and/or 504 Plan from a school district? _____Yes _____No
  If yes, Date of IEP or 504 Plan ____________________________

 Has the student ever received special education services (including early intervention)? ____Yes _____No
  If yes, Dates and types of service: ____________________________________________________________________
  ________________________________________________________________________________________________

 Please indicate all areas of strength:

    Reading:
    ____Comprehension what he/she reads on a “cold reading”              ____Using phonics                 ____Word attack
    ____Fluency                                                          ____Word recognition
    ____Using context clues                                              ____Vocabulary Comprehension

    Math:
    ____Solving story problems                         ____Understanding math concepts
    ____Solving math problems involving regrouping
    ____Math facts

    Language:
    ____Using correct capitalization and punctuation   ____Structuring complete paragraphs         ____Verbal
    ____Using correct verb tenses                      ____Composing complete sentences            ____Written
    ____Possesses adequate written expression skills   ____Spelling
    ____Grammar                                        ____Receptive

    General/Behavioral:
    ____Remaining on task                              ____Paying Attention
    ____Motivation                                     ____Turning in homework assignments
    ____Peer interactions                              ____Organizational skill
    ____Adult interaction                              ____Demonstrates persistence

 Please answer the following.
    a)   Does the student complete assignments?                 ___Yes   ___No
    b)   Does the student follow oral directions?               ___Yes   ___No
    c)   Does the student complete written directions?          ___Yes   ___No
    d)   Does the student work well within a group?             ___Yes   ___No
    e)   Does the student work well independently?              ___Yes   ___No
    f)   Does the student complete homework?                    ___Yes   ___No


 What strategies have been used in this child’s educational program to provide enrichment or acceleration to address
  the previously-mentioned strengths? (Specify length of time and results)_____________________________________
  ________________________________________________________________________________________________
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                                                                                             Request for Gifted Evaluation Form 2
 Please list any additional services the student is receiving (Title I, learning support, speech, tutoring, etc…):




 ** Please attach a copy of the student’s Grades and any Testing Results (SAT, ITBS, Terra Nova, etc…)
  ** Please attach any additional information that may be applicable (previous evaluations, outside evaluations,
       medical implications, any other assessment data available, etc…)

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School Administrator’s Signature                    Title                                Date




                                                                                       Request for Gifted Evaluation Form 3

								
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