SAMPLE: Request for District Evaluation

Italics indicate area that you will need to supply your personal information before sending the letter.

Address
City, state
Date

Dear Teacher’s name;

I am writing to request that an Occupational Therapy (or speech, behavioral, assistive technology, etc.) Evaluation be done on my child, Child’s name (birthdate XX-XX-XXXX). I have noticed particularly that whatever issue/condition/lack of progress may indicate a need for these services.

Thank you for seeing to this as soon as possible.


Sincerely,


Your name

cc: Anyone you wish to send a copy to