Navigate to [https://share.hsforms.com/1pWnNODeDRQ25f-zDRT0R1wd76zl](https://share.hsforms.com/1pWnNODeDRQ25f-zDRT0R1wd76zl)

Enter your email address, the student's ID number, and the name of your school.

Please Select
Alabama Connections Academy (ALCA)
Arizona Connections Academy (ACA)
Arkansas Connections Academy (ARCA)
California Connections Academy (CalCA) - *
Coastal Connections Academy (CoastalCA)
Colorado Connections Academy (ColoCA)
Falcon View Connections Academy (FVCA) *
Florida Connections Academy (FCA)
Georgia Connections Academy (GACA)
Great Lakes Connections Acadmey (GLLA)
Great River Connections Academy (GRCA)
Indiana Connections Academy (INCA)
Indiana Connections Career Academy (INCC)
Inspire Connections Academy (Inspire)
Iowa Connections Academy (IACA) *
Kansas Connections Academy (KCA)
Lighthouse Connections Academy (LCA)
Low Country Connections Academy (LCCA)
Maine Connections Academy (MCA)
Michigan Connections Academy (MICA) *
Minnesota Connections Academy (MNCA)
Missouri Connections Academy (MOCA)
Multiple School Locations - Admin Roles Only (Must list schools in help box)
Nevada Connections Academy (NCA)
Ohio Connections Academy (OCA)
Oklahoma Connections Academy (OKCA)
Oregon Connections Academy (ORCAP)
Pecos Cyber Academy *
Pennsylvania Connections Academy (REACH) *
South Carolina Connections (SCCA)
South Carolina Connections Academy (SCCA)
Tennessee Connections Academy (TNCAJ)
Texas Connections Academy (TCAH) *
Utah Connections Academy (UCA)
Virginia Connections Academy (VACA)
Washington Connections Academy (WACA)
Williamette Connections Academy (WillCA)
Wyoming Connections Academy (WYCA)

For "Type of Request" select "Extended School Year (ESY)."  You will be prompted to answer two more questions:

- Extended School Year? Select "Yes"
- ESY Time Period: Select current year

Scroll to the ESY Area section of the form.  You will be prompted to select the area of service for ESY.  If a student needs more than one area of ESY (ex: student requires both ESY LiveSpeech and ESY Counseling), you will submit one form per ESY service area.

Please Select
Adaptive Physical Education
Applied Behavior Analysis
Counseling
Hearing or Audiology
LiveSpeech
Nursing
Occupational Therapy
Orientation & Mobility
Other Service Not Listed
Other Speech/Language
Physical Therapy
Social Work
Vision or TVI

In the screenshot below, Occupational Therapy was selected as the area of ESY, so a field for ESY OT Details has displayed. When filling out the details field, follow the example by including the setting, area of related service, minutes, frequency, and duration.

Example: Virtual OT, 8 sessions at 30 minutes each, weekly sessions between June 1 and August 1

Enter a ticket name and description using the following naming conventions, then click submit.

Example: ESY_OT_MyCA_12345

Evaluation & Related Services Request Form
Once submitted, this form will automatically create a ticket that will be reviewed by the Operations Team.  You will receive notification when an evaluator or therapist has been assigned.  If you need to request more than one area of therapy or evaluation for the same student, please submit one form per area.  For example, a student who requires an OT evaluation and a psychological evaluation would need to have two forms submitted.
Email*
Please enter the e-mail address of the person submitting this request.
Student ID*
School Name*
Please Select
Alabama Connections Academy (ALCA)
Arizona Connections Academy (ACA)
Arkansas Connections Academy (ARCA)
California Connections Academy (CalCA) - *
Coastal Connections Academy (CoastalCA)
Colorado Connections Academy (ColoCA)
Falcon View Connections Academy (FVCA) *
Florida Connections Academy (FCA)
Georgia Connections Academy (GACA)
Great Lakes Connections Acadmey (GLLA)
Great River Connections Academy (GRCA)
Indiana Connections Academy (INCA)
Indiana Connections Career Academy (INCC)
Inspire Connections Academy (Inspire)
Iowa Connections Academy (IACA) *
Kansas Connections Academy (KCA)
Lighthouse Connections Academy (LCA)
Low Country Connections Academy (LCCA)
Maine Connections Academy (MCA)
Michigan Connections Academy (MICA) *
Minnesota Connections Academy (MNCA)
Missouri Connections Academy (MOCA)
Multiple School Locations - Admin Roles Only (Must list schools in help box)
Nevada Connections Academy (NCA)
Ohio Connections Academy (OCA)
Oklahoma Connections Academy (OKCA)
Oregon Connections Academy (ORCAP)
Pecos Cyber Academy *
Pennsylvania Connections Academy (REACH) *
South Carolina Connections (SCCA)
South Carolina Connections Academy (SCCA)
Tennessee Connections Academy (TNCAJ)
Texas Connections Academy (TCAH) *
Utah Connections Academy (UCA)
Virginia Connections Academy (VACA)
Washington Connections Academy (WACA)
Williamette Connections Academy (WillCA)
Wyoming Connections Academy (WYCA)
Zip code of Student
This field

Hsforms

This guide explains how to submit a ticket for ESY referrals for summer 2024.  The referral form will be used for both LiveSpeech and related services ESY referrals.

How to Submit a Ticket for ESY Referrals for LiveSpeech and Related Services