(Hand deliver and keep a dated and witnessed copy for your records)
Date:
To Whom It May Concern:
I, _______________, formally request complete psychological and achievement plus specific
testing of _______________for my son/daughter/custodial child, ____________,
(Date of Birth____________) to assess for the presence of a learning disability.
This is as per the request of my pediatrician.
Thank you very much.
Sincerely,
Received by:__________________ Date:_________
