FORM
21A
REFERRAL FOR
SPECIAL EDUCATION AND RELATED SERVICES
This form
is
used by school personnel when requesting an assessment
for
eligibility for special
education and related services.
A pupil
shall be referred for special educational
instruction and services only after the resources of
the
regular education program
have been considered and,
where appropriate,
utilized. EC 56303
• Student Name: Use legal first and last name.
• D.O.B.: Enter date of birth
• Grade: Enter
current grade designation.
• Name of parent or legal
guardian: Enter first
and
last name of parent or legal guardian.
• Address: Enter complete address and phone number.
• Date parent notified of intent
to
refer: Enter exact date parent notified.
• Method of
notifying parent of intent to refer: Check method used to notify parent.
• Parent’s native language: If other than English enter language or
primary mode of
communication.
• Primary Concern Regarding Student: This should be the specific reason or
area
where you suspect a disability.
• Specific Reason for Referral: Check the appropriate box or enter
a description of the reason
next
to “other”.
• General Education Interventions Attempts:
Describe the interventions attempted and
attach documentation.
• Name of Referring Person: Enter
the
name of referring person and title.
The bottom part of the form
“For District Use Only” is helps keep track of
the assessment timelines.
[Excerpted
from the State SELPA IEP Manual, July, 2013]