To schedule a Foreign Language Waiver evaluation with Dr. Kay-

• Call the office (717-569-6223) for a telephone intake with Robin or Sandy and schedule your appointment time.

• Complete one of the client intake forms below and return it to our office prior to (or at the time of) your appointment.

• Student Intake PDF or Student Intake Word

• Adult Intake PDF or Adult Intake Word

• Read the Notice of Privacy Practices and sign, date and return the HIPAA consent form to the office at the time of your appointment.

• HIPAA Consent PDF or HIPAA Consent Word

• Notice of Privacy Practices PDF format or Notice of Privacy Practices Word .doc

• Sign, date and return the Fee Policy and the Contract for Private Pay Evaluation to the office.

• Fee Policy PDF format or Fee Policy Word .doc

• Contract for Private Pay Evaluation PDF or Contract for Private Pay Evaluation Word

• If the evaluation is going to be paid for by the student's public school district, the district's representative
  will need to sign and return the Contract for District Pay Evaluation.

• Contract for District Pay Evaluation PDF or Contract for District Pay Evaluation Word

• Make as many copies of the Teacher Input Form as necessary and have them completed by teachers who are working with (or have worked with) the student.  

• Teacher Input form PDF format or Teacher Input form Word .doc

• Complete the Parent Input Form based upon observations of the child at home and the feedback received from teachers.

• Parent Input form PDF format or Parent Input form Word .doc

• Make a complete copy of the student's educational records and put them in chronological order from the oldest on top to current on bottom. Bring these with you to your appointment. They will be returned after the evaluation has been completed.

 Client Forms

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Last modified: July 11, 2010