ColleagueConsultationRequest Fillable .pdf
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Request for
OCCUPATIONAL THERAPY COLLEAGUE CONSULTATION
Prince George’s County Public Schools * Programs and Services * Occupational Therapy
John Carroll Building 1400 Nalley Terrace, Landover, Maryland 20785 * 240-696-3218
Please download this form then email a completed copy to your school’s assigned OT. You may also
email it to the OT office at Joanna.McGraw@pgcps.org.
Student’s Name_____________________
DOB: ____________________________
Student number: __________________
Grade: ___________
Program:
☐ ECC
☐ General Education
☐ Transitional Program
☐ Charter
☐ CSEP
☐ Autism
☐ CRI
☐ Regional
☐ Home and Hospital
☐ PARD
1.
2.
School: _____________________________Date___________
Has an IEP:
Has a 504:
☐ yes ☐no (if yes, disability:_______)
☐ yes ☐no (if yes, disability:________)
Has a service plan: ☐yes ☐no ( if yes, disability:________)
Area (s) of Primary Concern:
☐ Fine motor/Written communication
☐ Mealtime participation/Self-care
☐ Social participation
☐ Self-management
☐ Organization
☐ Emotional/Behavioral
☐ Pre-Vocational
☐ Managing materials
☐ Other:
Please describe how the above concern is impacting this student’s participation in the
classroom.
What data do you have to show the effectiveness/ineffectiveness of strategies that have been
implemented as part of the RTI process ?
If you need strategy ideas, please click on this link PGCPS CEIS/RTI Website Requests will not be
accepted without data.
Strategies
3.
Data (work samples,
observation record,
etc.)*please attach
Effective (Y/N)?
Please share any other additional information:
Person Completing Form____________________________________Position________________
Phone number____________________________ Email___________________________

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