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.