ࡱ>  Root Entry( JrXDMatOST 1DXDMMMN0ND ( JrMicrosoft Works MSWorksWPDoc9qS--T:&&&&i=/d&8t&8T STUDENT REFERRAL FOR SPECIAL EDUCATION DEPARTMENT OF SPECIAL EDUCATION/SEVIER COUNTY SCHOOLS Indirect Observation Date of Referral ____________________________ Student ____________________________________ Birthdate _____________ S.S. # ___________________ Last First Middle School _____________________ Homeroom Teacher _________________________ Grade _____ Phone #: Parent(s) ________________________________ Home: ___________________ Work ________________ Address __________________________________________________________________________________ Street City Zip Referring Persons Signature ____________________________________(Parent, LEA Personnel, or other) Describe Specific Academic Strengths/Weaknesses: _____________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Describe Specific Behavioral Strengths/Weaknesses: ____________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ INTERVENTIONS TRIED PRIOR TO REFERRAL: ___________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ REASONS FOR REFERRAL: (List specific concerns.) __________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ RECORDS REVIEW: Vision Screening: Date ______________Results: ___ Hearing Screening: Date _______________Results___ Other Relevant Health Information: ____________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________ Preschool Experience: Yes ___ No ___ N/A ___ (If yes, attach relevant documents such as assessment results and/or IFSP) Days absent last year: ____ Days Absent Current Year ____ Grades repeated: ___________ Currently receiving (mark all that apply): Title l ___ Speech/Language ____ OT/PT ____ Individual Counseling ____ Other ________________ The following records are attached (*required for all referrals; +as applicable): *Cumulative Records ___ *Discipline Records ___ *Classroom Observation(s) __ +TCAP (Terra Nova) Scores ___ +Competency Scores ___ +Writing Assessment ___ ------------------------------------------------------------------------------------------------------------------------------------ Disposition: Notice of referral sent to assessment specialist(s) and SPED office _________________________(date) Specify: __Psychologist __Sp/Lang __Vision __Hearing __OT/PT Other _______________ If applicable: Complete packet sent to psychologist _______________________(date) Rev. 8/98 ----------------------------------------------------------------------.e!/ U -8{u{q{q{q{q{q{q{k{q{k8:{.e{6Vr7Oqqkkkeeeeeeeeeeeeee !\p*  p & , 4 }yyyyyyyyyyyyyyyyyyyyyyy}8:yy8: }:!"#Times New Roman i=/i=/dCompObjU