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]