Procedures for Requesting an Evaluation

A dated letter should be sent to the chairperson of the district’s committee on special education. The name and address is included at the bottom of this page.

The letter should include the following:

Child’s Name
Child’s date of birth
Child’s address
Child’s grade
Child’s School
Reasons you are requesting the evaluation
Detailed difficulties your child is having & the impacts of those difficulties on your child

The letter should be sent to:

Mr. Chris Cinicola
CSE Chairperson
Department of Education
Committee on Special Education
82-01 Rockaway Blvd.,2nd Fl.
Ozone Park, NY, 11416

The following is a template for requesting an evaluation, which can be personalized depending on the child’s situation.

Date

Mr. Chris Cinicola
CSE Chairperson
Department of Education
82-01 Rockaway Blvd.,2nd Fl.
Ozone Park, NY, 11416
Phone number: 718-642-5715
Fax:(718) 642-5891

Dear Mr. Cinicola,

I am writing to request an (initial/speech/OT/PT) evaluation of my (child/student), (child’s name). (She/He) is _ years old and a ( ) grade student at St. Francis de Sales Catholic Academy,219 Beach 129th St, Belle Harbor, NY 11694.
I am requesting this evaluation because my (son/daughter/student) is having difficulty with (name difficulties). As a result of these difficulties, my child is experiencing (…).

If you have any questions please feel free to contact me at (your contact information).

Sincerely,

Parent Name

Child’s Information
Child’s name:
DOB: Grade:
Current Address:
Current Phone Number:
Parent’s Names:
School: St. Francis de Sales, 219 Beach 129 St., Belle Harbor, NY 11694
Phone: 718-634-2775 Fax: 718-634-6673