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Without all supporting required documents the application will not be considered.

The Jonathan Foundation (“TJF”) maintains affiliations with numerous proficient psychological educational assessors who have expressed their willingness to furnish assessments at a discounted rate. While TJF remains open to the consideration of all potential assessors, we retain the prerogative to select the assessor of choice and to establish the pricing for each assessment. Given the constraints of finite resources, TJF exercises prudence regarding assessment costs, yet this discretion is exercised in tandem with our commitment to funding a substantial number of assessments.

This disclaimer serves to communicate TJF’s position on assessor selection, pricing determination, and resource allocation pertaining to assessments.

SUBMIT INFORMATION

Apply for Assessments

CHILD'S NAME *

AGE *

BIRTH DATE *

ADDRESS

APPLICANT'S NAME: *

RELATIONSHIP TO CHILD: *

HOME PHONE: *

CELL PHONE: *

EMAIL: *

FAX:

SCHOOL: *

GRADE: *

DISTRICT: *

SELPA: *

DISABILITY: *

ELIGIBILITY CATEGORY FOR SPECIAL EDUCATION: *

WHO DIAGNOSED YOUR CHILD, if applicable: *

IS YOUR CHILD A CLIENT AND/OR RECEIVING SERVICES FROM:

THE REGIONAL CENTER?: *YesNo

WHICH REGIONAL CENTER: *

CONSUMER SERVICES COORDINATOR: *

CALIFORNIA CHILDRENS SERVICES?: *YesNo

DEPARTMENT OF MENTAL HEALTH?: *YesNo

DID OR DOES YOUR CHILD HAVE AN IEP?: *YesNo

WHAT IS THE DATE OF YOUR CHILD'S MOST RECENT IEP, if applicable?: *

WHEN IS THE NEXT TRIENNIAL (3-YR) REVIEW IEP?: *

WHEN WAS YOUR CHILD LAST ASSESSED BY THE SCHOOL DISTRICT?: *

WHO CONDUCTED THE ASSESSMENT(S): *

School PsychologistSpeech SpecialistTeacher (Special Ed., Resource, Gen Ed.)Occupational TherapistBehavior SpecialistOther

IS YOUR CHILD ON: *

School PsychologistSpeech Specialist

WHY ARE YOU APPLYING FOR AN ASSESSMENT SCHOLARSHIP?: *

Special Education EligibilityRegional Center EligibilityRelated Services EligibilityIndependent Educational EvaluationPrivate EvaluationPurpose

PLEASE EXPLAIN (Attach additional pages, if needed):

ARE YOU APPLYING FOR A: *FULLPARTIAL SCHOLARSHIP?

HAVE YOU PAID FOR ANY PRIVATE OR OUTSIDE EVALUATIONS?: *YesNo

IF SO, WHAT TYPE OF EVALUATION(S)?: *

WHAT WAS THE PURPOSE OF THE EVALUATION(S)?: *

WHO PERFORMED THE EVALUATION(S)?: *

WHEN WERE THE EVALUATION(S) COMPLETED?: *

WHAT TYPE OF ASSESSMENT ARE YOU SEEKING: *

PsychoeducationalNeuropsychologicalSpeech & LanguageBehavioralOccupational TherapyExtensive Social / Emotional (ERICS/ERMHS)Other

HAVE YOU TRIED TO OBTAIN THE REQUESTED ASSESSMENT FROM THE SCHOOL, DISTRICT, OR REGIONAL CENTER?: *YesNo

HAVE YOU WORKED WITH AN ATTORNEY OR ADVOCATE?: *YesNo

IF SO, ARE YOU STILL WORKING WITH THIS PERSON?: *YesNo

FIRST TWO PAGES OF 1040- MASK SOCIAL SECURITY NUMBERS: *

No file chosen

TWO WEEK PAYCHECK STUB: *

No file chosen

ONE PAGE FINANCIAL HARDSHIP SUMMARY: *

No file chosen

ONE PAGE OF WHY THE ASSESSMENT REQUESTED: *

No file chosen

Important Note: While decisions regarding the approval/denial of scholarship applications generally will be made within 30 business days, The Jonathan Foundation, Inc. (“TJF”) may require additional information to be submitted in order for us to make such decisions. If additional information is needed, TJF may need to extend the time frame by which it will provide applicants with a decision.