 Provider Name

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 Student Name
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 Type of Service Delivered
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 Student Attendance: # of sessions attended vs. # of sessions available
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 Delineate each IEP goal and their progress, as appropriate to the service(s) you provide.* Be
sure to include standards if possible
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 Do you have a proposal for new or updated IEP goals? If so, please include the proposal here.
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 Do you feel the current SDIs being implemented are appropriate based on the student's needs?
Would you recommend new or additional SDIs moving forward?
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 Please summarize, in a strength-based paragraph, your overall professional impressions of the
student.
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 FOR SCHOOL USE ONLY: Are you making a recommendation for ESY services? If yes, please
include data and rationalization here. (We will be using PDEs guidelines to verify eligibility.)
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 FOR SCHOOL USE ONLY: Do you have any concerns that you would like to share with the case
manager?
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