GUIDE TO THE REFERRAL FOR SPECIALIZED ASSESSMENT APPLICATION FORM 2022-2023
This guide is intended to support school authorities in the completion of the Referral for Specialized Assessment Application form.
- To access the referral form, follow the link provided here.
- Fill out form & gather all supporting documents for each student. One form per student requiring an assessment, whether individual or multiple assessments are being requested.
- Send form and supporting documents to firstname.lastname@example.org by attachment only.
- Please do not send links to a drive/folder, these will not be accepted.
- All attachments should be in PDF format and separated by student. Please do not send multiple referral forms in one attachment.
Once an email has been received with attachments, a reply email will be sent advising we have received the referral(s) and that we will be in touch if more information is needed or if a student is not eligible. We will always reach out if a student is deemed ineligible to see if there is more documentation to provide or to clarify issues, as our goal is to approve as many as possible. Once a student has been assigned to an assessor, the assessor will reach out directly to the school and we will send an email to the contact on the referral form. Please contact email@example.com for more information regarding the application process.
All sections of the Referral for Specialized Assessment Application form must be completed in full for each child/student being referred for a specialized assessment. Incomplete forms will not be accepted.
School Authorities can submit referrals to the service coordinator via the link provided beginning on January 1st, 2023. The deadline for submission is March 1st, 2023 (4:00 pm/MST).
Is there space available in your school for the assessment to take place (Part A)?
When completing this question, please consider the following: In order to conduct the assessment, the designated service provider will require access to a quite space for the duration of the scheduled assessment time. Minimally, the space should be quiet, include a desk/table, and adequate lighting. If space is not available, alternative arrangements will be made in coordination with the service provider.
When addressing the functional impact (Part D), please refer to the following:
- Mild – Area(s) of concern sometimes always impacts the child’s/student’s ability learn and/or successfully navigate socially and emotionally in the school environment.
- Moderate – Area(s) of concern often impacts the child’s/student’s ability learn and/or successfully navigate socially and emotionally in the school environment.
- Severe – Area(s) of concern always impacts the child’s/student’s ability learn and/or successfully navigate socially and emotionally in the school environment.
When determining whether the child/student currently utilizes additional school resources, please consider the following (Part D):
Additional school resources refers to any supports or services provided beyond that which all children/students receive as part of their programming. This may include but is not limited to the following: support of an educational assistant, program modifications or accommodations, school-based social-emotional supports (e.g., school counsellor, child development advisor, psychologist), school-based therapeutic supports (e.g., speech-language pathology, occupational therapy).
Documentation supporting the length of time the child/student has been waiting for a specialized assessment is required at the time of referral (Part D). Acceptable documentation may include, but is not limited to, a referral form requesting a specialized assessment that has not been completed, an Individualized Program Plan (IPP) that indicates a need for additional diagnostic information, a recommendation in a report for additional specialized assessments.
The assessment/discipline requested should coincide with the type of assessment the child/student has been on.
PART E: REQUEST FOR SERVICE
Select from the drop-down menu, the area of assessment/discipline being requested. Options include the following: Audiology, Occupational Therapy, Physical Therapy, Psychology, Speech-Language pathology, Vision. The selection should coincide with the type of assessment the child/student has been on the waitlist for.
PART F: DECLARATION STATEMENT
By checking the boxes in Part F, the undersigned declares that (1) The child/student has been waiting for a specialized assessment for at least six months as of June 30, 2022; AND (2) Parents/Guardians of the child/student being referred are aware of the request for specialized assessment. Note: Informed consent will be obtained by the contracted professional.