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 2009. For the 2008-2009 form set.]