Special Services Referral - Text Version

SAU 40 - Milford School District

Office of Special Services (603) 673-6709 Fax (603) 673-9883

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☐ Jacques Memorial Elementary School

☐ Milford Middle School

☐ Project DRIVE

☐ Heron Pond Elementary School

☐ Milford High School

☐ Out of District  _________________

 

 

REFERRAL FOR SPECIAL EDUCATION

 

The NH Rules for the Education of Children with Disabilities states "any person may refer a child under the age of 21 years to the IEP team for reasons including but not limited to the following: (1) Failing to pass a hearing or vision screening; (2) Unsatisfactory performance on group achievement tests or accountability measures; (3) Receiving multiple academic and behavioral warnings or suspension or expulsion from a child care or after school program; 4) Repeatedly failing one or more subjects; 5) Inability to progress or participate in developmentally appropriate preschool activities; and 6) Receiving service from family centered early support and services" (Ed. 1 105.02).

 

Student:		Parent/Guardian:
Birthdate:		Daytime Phone:
Address:		Address:
School:		Email:
Grade/Teacher:		Referral Source:
Date of this Referral:		Date Referral was Received:

 

PLEASE ANSWER THE FOLLOWING QUESTIONS.

 

Why are you referring this student to special education?

Please describe the student's current skill levels.

Reading:

Writing:

Mathematics:

Behavior:

Communication:

Social/ Emotional:

Organization/Attention:

Other:

 

Did the student score proficient on statewide/standardized assessments? ☐Yes ☐No

Has this student been referred to special education in the past? ☐Yes ☐No

If so, when?

 

 

Please list any current diagnoses:
DIAGNOSIS	PROVIDER
1. Is there anything else you would like the special education Team to know about the student?
2. List the interventions (at home & at school) that have been attempted to assist the student:
3. What is the desired outcome of this special education referral?

 

"The LEA shall, upon receipt of a referral from any source, immediately notify the parent, in writing, of the referral. In addition, the IEP team shall within 15 business days of the referral, determine whether the concerns raised by the referral can be addressed utilizing existing pupil support services available to all children, whether additional information is required, and what testing, if any, is needed to address any remaining concerns raised by the referral about how the referral is determined" (Ed. 1106.01).

 

Revised 8/20/2018