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 Does 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 having uploading documents please email as an attachment to email@example.comVision Required DocumentsPlease upload the vision report. Failure to upload will delay the process. If you are having uploading documents please email as an attachment to firstname.lastname@example.orgImportant Additional Information RequiredPlease upload your district's pre-referral, referral, parent consent to evaluate and any other pertinent documents. If you are unable to upload file please email to email@example.com Drop files here or EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.