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Forms (Schedule an Evaluation)


 
To schedule a KanLovKids Clinic 
Low Vision Collaboration Clinic (LVCC) or  
Low Vision Collaboration Clinic + (LVCC+)

Please contact your KSSB Regional Field Services Specialist  to schedule a clinic in your area and to discuss which type of Low Vision Clinic would be more appropriate.  
Please note: Schedules will be completed with your Regional Field Services Specialist. 
Questions? -- contact KanLovKids Coordinator, Judy Imber      jimber@kssdb.org    913-305-3043

 Area ServedField Services Specialist  PhoneEmail 
 Southeast RegionJulie Ituarte913-945-0769jituarte@kssdb.org
 Northeast/KC Metro RegionJudy Imber913-305-3043jimber@kssdb.org  
 Central/North Central   RegionAnna Cyr913-645-5324 acyr@kssdb.org
 South Central RegionDebbie Moody913-982-7712 dmoody@kssdb.org
 Western Region:Menely Hogan 913-645-2659mhogan@kssdb.org

  • The Regional Field Services Specialist will contact the doctor’s office to setup a date and time for the evaluations and then send you a Clinic Schedule for you to complete and return.
  • Forms for the clinics (LVCC or LVCC+) can be downloaded from the KanLovKids website at http://kanlovkids.kssdb.org in a pdf format.
Information needed for Low Vision Collaboration Clinic are: When emailing documents, please put clinic date in the subject box.
  1. Consent Letter
  2. Contact Information Form (Use Child/Student’s Legal Name)
  3. Patient's Eye Doctor Information
  4. Provide the most recent Eye Report, Functional Vision/ Learning Media Assessment, Clinic Low Vision Evaluation, and Orientation and Mobility Report
  5. Media Consent Form 
  6. Low Vision Clinic Parent Letter (please fill this out BEFORE sending it home to parents --parents keep this)
  7.       ** Impact of Vision Impairment for Children (IVI-C for 12 to 18 years of age)**                      **Fill this out  only if KSSB Field Services Specialists requests it for the doctor**                         This form should be completed online, as it will be automatically scored. 
Please email documents (1-5) to Erin Kelly  ekelly@kssdb.org   913-305-3061      
ALL DOCUMENTS ARE  DUE ONE MONTH BEFORE CLINIC DATE  
BRING SAMPLES OF STUDENT’S WORKSHEETS, TEXTBOOKS, ETC.

Information needed for  Low Vision Collaboration Clinic+ are: When emailing documents, please put clinic date in the subject box.
  1. Consent Letter
  2. Contact Information Form (Use Child/Student’s Legal Name);
  3. Child-Student Eye Doctor's Information
  4. Child Family History Form
  5. Release form from Dr. Linda Lawrence's office (only needed for Dr. Lawrence's clinics) Do not write KanLovKids on it
  6. Provide the most recent Eye Report, Functional Vision/ Learning Media Assessment, Clinic Low Vision Evaluation, Medical Records and Orientation and Mobility Report
  7. Media Consent Form
  8. Parent / Guardian Low Vision Collaboration Clinic+ Letter (please fill this out BEFORE sending home to parents--parents keep this)
Please email documents (1-7) listed to Erin Kelly  ekelly@kssdb.org   913-305-3061     
 ALL DOCUMENTS ARE  DUE ONE MONTH BEFORE CLINIC DATE  
BRING SUPPORTED SEATING EQUIPMENT AND TRAVEL OR WHEELCHAIR TRAYS, ALONG WITH TOYS OR OBJECTS THE CHILD PREFERS.
________________________________________________________________________________________________________________
  • Erin Kelly will upload the completed documents in KSSB’s Google Drive so that the doctor will have on-line access to prepare for the evaluation.
  • After the evaluation, a report will be generated by the doctor and distributed to the TSVI/ECI to deliver to the family and school.
  • KSSB will send an invoice to your district after completion of the LVC or LVCC+ for the children/students assessed.  The invoice will be sent to the designated person indicated by you on the Contact Information Form. Services for birth-three will not be billed (do not fill out billing contact info).
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