Submit Request and Evaluation Intake Form

Please complete all fields. Be as thorough as possible in all your responses. Fields marked with an asterisk (*) are required.
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Intake Information

How did you hear about the SCPS Non-Public Services?

* Reason for request

Student Information

* Student's Legal First Name

Student's Legal Middle Name

* Student's Legal Last Name

* Date of Birth

* Grade

* Student's Birthplace (include city, state and country)

* Student's Gender

* Student's Race

* Federal Ethnic Category

Date first enrolled in a school in the United States

* What languages are spoken in the home? (Select all that apply)

English

Spanish

Haitian Creole

Other (please specify below)

Check all languages that are spoken in your home

* What language does your child speak most frequently?

* What language did your child learn to speak first?

School Information

What is your child's public school FLEID number (if known and applicable; any Florida county)

* Please indicate your child’s current method of schooling:

What is the name of your child's current teacher?

* Has your child ever been retained? If yes, please indicate which grade(s)

* Please list all schools your child has attended, the grade level(s) and location of the schools, including pre-school Please list all schools your child has attended, including grade levels and locations.

* Is your child currently attending school face to face, virtually or both? Please include any dates your child was attending virtually, if applicable Please include any dates your child was attending virtually, if applicable.

* If your child receives a scholarship, please indicate the type below. If your child does not receive a scholarship, indicate "None" If your child does not receive a scholarship, indicate "None".

Special Education Information

* Has any public school or public school district ever developed an Individual Education Plan (IEP) for your child?

* Has any public school or public school district ever developed a 504 Plan for your child?

If yes to either, please attach a copy of the latest 504 or IEP (PDF) in the supporting documents section at the end of this form.

Student Strengths and Concerns

* Which academic areas does your child excel in? (such as reading, writing, math, etc.) Such as Reading, Writing, and Math

* Tell us areas of interest in which your child excels (such as extracurricular activities, arts, music, technologies) Such as extracurricular activities, arts, music, technologies

* Do you have academic concerns for your child? If yes, please be specific in your response. If there are no concerns, please indicate none. Please be as thorough as possible in your response

* Do you have independent functioning concerns for your child? If yes, please be specific in your response. If there are no concerns, please indicate none. Please be as thorough as possible in your response

* Do you have social/emotional concerns for your child? If yes, please be specific in your response. If there are no concerns, please indicate none. Please be as thorough as possible in your response

Tell us anything else you want us to know about your child

Speech and Language

* Are you able to understand your child when he/she speaks? If no, please explain If no, please explain

* Are others able to understand your child when he/she speaks? If no, please explain If no, please explain

Parent/Guardian Information

* First Name

* Last Name

* Relationship to Student

* Email

* Primary Phone Number

* Current Residential Address

* City

* State

* Zip Code

Supporting Documents

Required Items: Please submit the below listed information about your child.

Parent / Legal Guardian official Picture ID (Driver's license, state ID, passport)
Student's birth certificate (If you are not listed on the birth certificate, also include documents for legal or educational guardianship. If relevant, include custody documentation.)

If applicable to your child, please provide as many of the following items as possible:

Most recent hearing and vision screening
Private Therapy Reports and Data
Medical or private evaluations related to concerns
Your child's most recent copy of the IEP (Individual Education Plan) or 504 Plan (Individual Accommodations Plan)

Please upload the requested documents, including parent/legal guardian's picture ID and child's birth certificate. Processing your request will be delayed if documents are missing.

Document

Accepted file types: PDF, DOC, DOCX, JPG, PNG. Maximum file size: 10MB each.

You can upload multiple documents. Click "Add Another Document" to add more upload fields.

Consent and Agreement

Please read each statement carefully and select "Yes" to acknowledge your agreement.

* By completing this questionnaire, I understand diagnostic services through SCPS Non-Public is voluntary and I may revoke my request in writing by mail or by email at any time during this process.

Yes

* By completing this questionnaire, I agree that I will contact SCPS Non-Public Services of any changes to information provided on this form (this includes, but not limited to changes in my child's school, my residential address and phone number).

Yes

* By completing this questionnaire, I give permission for SCPS to contact my child's non-public school to request school information.

Yes

* By completing this questionnaire, I hereby request that school information be provided to SCPS Non-Public Services.

Yes

* By completing this questionnaire, I verify that I am the parent/guardian of the student identified in this form.

Yes

* By completing this evaluation request intake packet, I understand that I am requesting diagnostic services for my child who is not currently enrolled in a public school.

Yes

Important: All consent items above must be acknowledged before you can submit your application.

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