Move-In Report _______________________ Primary Exceptionality: ____________________________
Preassessment Information _______________________ Secondary Exceptionality: __________________________
Consent to Evaluate _______________________
Health Report _______________________ ServiceSettingTimeProvider
Classroom Teacher’s Report _______________________ ______ _____ ___________ ________________
Special Ed. Teacher’s Report _______________________ ______ _____ ___________ ________________
Psychologist’s Report _______________________ ______ _____ ___________ ________________
Speech Clinician’s Report _______________________ ______ _____ ___________ ________________
OT / PT Report _______________________ ______ _____ ___________ ________________
Other Reports _______________________ ______ ______ ____________ ________________
Multidisciplinary Report _______________________
Parent Conference Notice _______________________ Behavior Plan:
Yes
No
Consent for Placement _______________________ Special Transportation:
Yes
No
Staffing Summary _______________________ Extended School Year:
Yes
No
I.E.P. _______________________ Medicaid Parent Release Form:
Yes
No
Vision Screening Date: _______________________ Hearing Screening Date: _______________________
Date Move-in completed: _____________________ Reevaluation Due Date: _____________________
Date IEP Due: _____________________
_______________________________________________ _________________________________________________
Case Managing Psychologist Special Education Administrator