All Forms

Margaret J. Kay, Ed.D. Psychologist
Nationally Certified School Psychologist (NCSP)
Pennsylvania Licensed Psychologist #PS003431L
Delaware Licensed Psychologist #B10000780
Pennsylvania Certified School Psychologist #5961681
National Provider ID: #1013058585

Lancaster PA Office (Main)
2818 Lititz Pike
Lancaster, PA 17601-3322
Phone: (717) 569-6223
FAX: (717) 560-9931
Email: MJK@MargaretKay.com

Delaware Office (IEEusa.net)
32828 Reba Road, Suite A
Millville, DE 19967
Phone: (302) 539-1346
FAX: (717) 560-9931
Email: psych5@margaretkay.com

Forms to Schedule an Evaluation

To schedule an evaluation in Lancaster, PA Office	To schedule an evaluation in Millville, DE Office

1. Call the office (717) 569-6223 for telephone intake	1. Call the office (302) 539-1346 for telephone intake
2. Complete & Return Client Intake Form: Student or Adult	2. Complete & Return Client Intake Form: Student or Adult
3. Read Notice of Privacy Practices & sign/date HIPAA Consent	3. Read Notice of Privacy Practices & sign/date HIPAA Consent
4. Sign, date & return Fee Policy & Contract for Private Pay Evaluation	4. Sign, date & return Fee Policy & Contract for Private Pay Evaluation
5. Complete this contract if this is a District Funded IEE	5. Complete this contract if this is a District Funded IEE
6. Complete this permission to exchange if this is a District Funded IEE	6. Complete this permission to exchange if this is a District Funded IEE
7. Complete Parent Input Form (s)	6. Complete Parent Input Form (s)
8. Have all teachers complete Teacher Input Forms	7. Have all teachers complete Teacher Input Forms
9. Copy or bring in student's educational Records (will be returned)	8. Copy or bring in student's educational Records (will be returned)
10. Arrive at scheduled time/date for appointment	10. Arrive at scheduled time/date for appointment

Client Forms in PDF and Word.doc Formats

Forms to Schedule an Evaluation PDF	Forms to Schedule an Evaluation WORD
Adult Intake PA Adult Intake DE	Adult Intake PA Adult Intake DE
Student Intake PA Student Intake DE	Student Intake PA Student Intake DE
Parent Input Form PA Parent Input Form DE	Parent Input Form PA Parent Input Form DE
Teacher Input Form PA Teacher Input Form DE	Teacher Input Form PA Teacher Input Form DE
Consent for Treatment PA and Delaware	Consent for Treatment PA and Delaware
Contract for Private Pay IEE - PA and DE	Contract for Private Pay IEE - PA and DE
Contract for School District IEE - PA and DE	Contract for School District IEE - PA and DE
Fee Policy - PA and DE	Fee Policy - PA and DE
Notice of Privacy Practices	Notice of Privacy Practices

Information about IEE's PDF	Information about IEE's WORD
IDEA 2004 Statute for IEE	IDEA Statute for IEE
Districts that have Contracted for IEE's	Districts that have Contracted for IEE's
Educational Hearings in which MJK has Testified	Educational Hearings in which MJK has Testified
OSEP Criteria for IEE	OSEP Criteria for IEE
VITA Margaret Kay	VITA Margaret Kay
Directions to Offices - PA and DE	Directions to Offices - PA and DE

Retainer Contracts	Retainer Contracts
Retainer Contract for In-Person Educational Due Process	Retainer Contract for In-Person Educational Due Process
Retainer Contract for Telephone Testimony	Retainer Contract for Telephone Testimony
Retainer Contract for School Observation	Retainer Contract for School Observation

Practice Brochures

Autism & Asperger's Diagnostic Services	Foreign Language Waiver Evaluations
IEE Fact Sheet	Neuropsychological Evaluaitons

This site was designed by Margaret J. Kay, Ed.D. Its contents are presented for informational and educational purposes only and are not to be construed as professional advice on medical, legal, technical or therapeutic matters. By using and accessing the information on this site, you agree to waive any rights to hold the site developer, or any individual and/or group associated with this site, liable for any damage that may result from the use of the information presented here.

� Copyright 2012 Margaret J. Kay. All rights reserved.

The copyright of design, text and images on this web site is owned by Margaret J. Kay or the individual copyright owners as noted elsewhere on this site. You may download and reprint articles from this web site for non-commercial, private, educational purposes only. You may not in any way modify, or publicly distribute, any information contained within this site without specific permission form the copyright owner.

Send mail to MJK@MargaretKay.com with questions or comments about this web site.

Last modified: April 13, 2012