Psychological Assessment Log
LEA Name:	Psychologist’s Name:
Student’s Name:	PA Secure ID:	Date of Birth:
Diagnosis/Symptom(s):
Initial Evaluation Re-evaluation

Evaluation Activity	Date	Time	Date	Time	Total Time
hrs.	min.
Preparing and Sending Correspondence to Other Professionals
Administering and Scoring Psychological Tests
Completing Classroom Observation
Consulting with Teacher / Staff
Meeting with Parents (excluding IEP meeting)
Report Writing
IEP Date (Billing Date)
Total Time

Psychologist’s Signature:
Date:
Note: Only psychological assessments that lead to and result in the creation of an IEP or the continuation of an IEP can be billed to Medical Assistance.
Notes (optional):

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Psychological Assessment Log

Leader Services

2013-03-11

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Leader Services

Leader Services