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is the main reason you are seeking evaluation at this time? What are the chief concerns that you would like help with? CURRENT SCHOOL: GRADE: TEACHER: Check those that apply: â–¡ Special Education â–¡ Regular Education â–¡ Resource Room â–¡ Has IEP â–¡ Has 504 Plan Specify setting: â–¡ 12:1:1 â–¡ 6:1:1 â–¡ Inclusion â–¡ Other: ______________ I. General Information Child name (last, first) Age Person completing form Relationship Today's date Parent/Guardian Home phone Cell phone Add.

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