LAURENS COUNTY SCHOOL DISTRICT NO. 55 1029 WEST MAIN STEET LAURENS, SC 29360 OFFICE OF PROGRAMS FOR CHILDREN WITH DISABILITIES ACCEPTANCE OF PSYCHOLOGICAL AND/OR SPEECH EVALUATION Student’s Full Name: _______________________________________ Birth Date: __________ School: ___________________________________________________ Sex: M / F Parent/Guardian’s Name: _________________________________________________________ Address: ______________________________________________________________________ City: _______________________________

State: SC

Zip Code: _____________________

Telephone: ____________________________________________________________________

I accept the psychological evaluation and/or speech evaluation dated ______________________ by ________________________________ from ______________________________________ _____________________________________________________ School Psychologist II Date _____________________________________________________ Speech Therapist Date _____ Additional evaluation is needed to determine continued eligibility under the SC Department of Education regulations. _____________________________________________________ School Psychologist II Date _____________________________________________________ Speech Therapist Date

List attempts to secure the psychological evaluation and/or speech evaluation: Date: _____________________ Contact: ____________________________________________ Requested:_____ Psychological Evaluation _____ Speech Evaluation Date: _____________________ Contact: ____________________________________________ Requested:_____ Psychological Evaluation _____ Speech Evaluation

LCSD 55 07-15