Request for Services (CORP) HDESD Request for Evaluation / Service Your Name* First Last Email* Phone*Student Name* First Last Student Date of Birth (DOB)* MM DD YYYY Is this student*EIECSESchool AgePost SecondaryDoes this student have a current IEP/IFSP?*YesNoStudent School District*Bend-LaPineCrook CountyCulverHarney CountyHDESD EI/ECSEJeffersonNorth CentralRedmondSistersStudent School*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 firstname.lastname@example.orgVision 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 email@example.comImportant 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 firstname.lastname@example.org Drop files here or CommentsThis field is for validation purposes and should be left unchanged.