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| IDENTIFYING DATA | |
Birthdate (mm/dd/yyyy): ____________ | |
| Student's Name: _______________________________________________ |
Home Address: | Phone: ________________________ |
_______________________________ _______________________________ | |
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| Who is Responsible for the Child? | |
q Mother q Father q Guardian | |
| Name(s): _____________________________________________________________________________ |
| Home Address: | Other Address (if applicable): |
__________________________________ __________________________________ | __________________________________ __________________________________ |
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| Phone(s): | Work Phone(s): |
Mother _______________________ Father _______________________ Guardian _______________________ | Mother _______________________ Father _______________________ Guardian _______________________ |
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| Parent's Native Language (if not English): _____________________________________________________ |
| Student's Native Language (if not English): ____________________________________________________ |
| Student ID Number (as appropriate): ___________________ | |
| Building of Current Attendance: _______________________ | Grade: __________ |
Present Teacher(s): __________________________________________________________________________________________ |
Referral Reason: ____________________________________________________________________________________________ ____________________________________________________________________________________________________________ |
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| EDUCATIONAL HISTORY | |
Indicate any current or past supplemental programs/services or interventions (e.g., Title 1, early intervention services, preK, Reading Recovery, individualized interventions). ____________________________________________________________________ ____________________________________________________________________________________________________________ |
| Provide data that demonstrates that the student was provided appropriate instruction in regular educational settings, delivered by qualified professionals. |
| Provide data based on documentation of repeated assessments of achievement at reasonable, intervals, reflecting formal assessments of student's progress during instruction which was provided to the parents. |
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| Number of school districts attended: ___________________ | Years at present school building: _________________________ |
List schools/early childhood programs & date (mm/dd/yyyy): ______________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ |
| Attendance: q Regular q Irregular (explain) |
Is this student age-appropriate for grade level? q Yes q No |
If No, check all that apply | |
q Retained (specify grade) __________ q Enrolled late in school q Held out of school by parent q Unknown | |
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| BACKGROUND INFORMATION | |
| A. Health Data | |
| Do you suspect problems with q Vision q Hearing |
Does the student wear q Glasses q Hearing Aid(s) |
| Does the student take medication q Yes q No | |
If Yes, specify type and purpose: _________________________________________________________________________________ |
| Does the student have any health/developmental/physical problems of which you are aware? q Yes q No |
If Yes, please explain: _________________________________________________________________________________________ |
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| B. Environmental Factors | |
Describe any specific home factors that might affect the student's performance in school: __________________________________ ____________________________________________________________________________________________________________ |
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| For PreK Children Only (please check the area(s) of concern): |
q Eating q Dressing | q Toileting q Attention |
| q Receptive Communication q Expressive Communication | q Hearing |
| q Cognitive q Fine Motor | q Play q Gross Motor |
| q Vision q Social/Emotional Behavior | |
| Other | |
Describe any other pertinent information not previously described: _____________________________________________________ ____________________________________________________________________________________________________________ |
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| __________________________________ | ___________________________________ |
Signature of Person Initiating the Referral | Signature of Person Receiving the Referral |
| __________________________________ | ___________________________________ |
Position or Relationship to Student | Title |
__________________________________ | ___________________________________ |
Date (mm/dd/yyyy) | Date Received (mm/dd/yyyy) |
| ___________________________________ |
| Date District Suspects a Disability (mm/dd/yyyy) |
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