Referral for Special Education

Student	DOB	Grade
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School	District	Phone
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Parent/Guardian/Surrogate Parent
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Street Address	Town/City	State	Zip Code	Phone
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Date of Referral	Person Making Referral	Relationship to Student
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Date of Receipt of Referral

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Date of Receipt of Referral Letter Sent

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Date of Disposition Meeting

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Date Disposition Letter was sent

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Describe the action taken within 15 days

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School Contact Person

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Briefly Describe Your Concerns (please include any test scores)

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Describe any prior or current interventions, how long they were implemented, and their results

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