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Evaluation of your student recommended for AI consult/placement: NAME: DISTRICT: DATE: SCHOOL BLDG: PHONE NUMBER: CURRENT EDUCATIONAL PLACEMENT: TEAM MEMBERS: (if applicable) TEACHER/PRIMARY PROVIDER: PHONE: SOCIAL WORKER: OCCUPATIONAL THERAPIST: PHYSICAL THERAPIST: SPEECH THERAPIST: OTHER: 1. Please state reasons for AI Consultation request. Communication, social skills, sensory, etc. Briefly describe current student needs. 2. Describe the social interaction with adults and peer.
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