Special Education Referral: Preschool
C: EC File, Parent/Guardian Student UID#:
_______________________
Student:
Student UID#
DOB:
School:
Grade:
Age:
SPECIAL EDUCATION REFERRAL – Preschool
Meeting Date:
Date School Received Written Referral:
Referral Source:
Referral Source Position:
Parent/Guardian/Student:
Name:
Email:
Address:
City/Zip:
Home Phone:
Alternate Phone:
I. Discussion of Student’s Strengths (Must address all areas.)
Describe the student’s strengths in the following areas.
Cognitive/thinking skills: (attention, memory, problem-solving, complexity of play, pre-academics)
Emotional and social skills: (expressing and managing feelings, managing behavior, responding to rules and
limits, social interactions with other people including other children)
Communication skills: (understanding of language, use of language, speech sound development, quality of voice,
fluency)
Special Education Referral: Preschool
C: EC File, Parent/Guardian Student UID#:
_______________________
Sensorimotor skills: (vision and hearing, gross motor development, fine and visual-motor development, sensory
processing)
Adaptive skills: (independence with feeding, dressing/undressing, toileting, bathing)
II. Review of Existing Data by IEP Team Members (Must address all areas if data is
available.)
Describe early history and all relevant medical/health information. (diagnoses, procedures,
medications, illnesses/injuries including head injuries)
Describe results of local screening data. (e.g. Child Find, etc.)
Special Education Referral: Preschool
C: EC File, Parent/Guardian Student UID#:
_______________________
Were formal evaluation results provided by the parent/guardian? yes no
If yes, describe the results:
Describe observations of overall child functioning by teachers, therapists, related service
providers, and/or administrators. Include the setting and other children/care givers present.
Describe any instructional practices/interventions implemented to address area(s) of concern
and outcomes of those practices/interventions. (e.g. IFSP/IEP progress, private therapy, general
education interventions, etc.)
Is this child making a transition form Part C – Infant/Toddler Program (Early Intervention/EI)?
yes no
If yes, please complete the following:
Date of Transition Planning Conference (TPC):
Who referred the child for Early Intervention services?
Age at which child started receiving Early Intervention services/child
service coordination:
Age at which child stopped receiving Early Intervention
services/child service coordination: (if applicable)
Vision Screening
Is there existing Vision Screening data available? Yes No
Date:
Pass
Fail
Vision Screening Results Obtained:
Far
Right
Left
With Glasses or Corrective Lenses
Near
Right
Left
Without Glasses or Corrective Lenses
Both
Special Education Referral: Preschool
C: EC File, Parent/Guardian Student UID#:
_______________________
Comments:
Hearing Screening
Is there existing Hearing Screening data available? Yes No
Date:
Pass
Fail
dB
(Intensity Level)
Hz
(Frequencies)
Comments:
Existing Evaluation and Screening Data
Assessment Area
Summary of Required Screenings and
Evaluations (Existing data only). Any new
assessment or screening for the purposes of eligibility
determination requires parent/guardian/student consent.
Assessment Area
Summary of Required Screenings and
Evaluations (Existing data only). Any new
assessment or screening for the purposes of eligibility
determination requires parent/guardian/student consent.
Special Education Referral: Preschool
C: EC File, Parent/Guardian Student UID#:
_______________________
III. Reason(s) for Referral/Areas of Suspected Need
Based on the existing available data, the following targeted areas of cognitive/thinking skills;
emotional and social skills; communication skills; sensorimotor skills; and/or adaptive skills are
noted by the team:
IV. IEP Team Determination
No evaluation will be conducted based on the review of existing data. The referral to
special education ends.
Explain decision not to evaluate:
Eligibility for special education and related services is being determined by existing
evaluation data made available to the IEP Team through the Special Education Referral.
NO additional evaluation(s) are needed to determine eligibility.
Assessment information and evaluation data used to make this determination can be found in the
assessment area table. (Note: This data must meet the requirements of the eligibility worksheet(s)).
Conduct an initial evaluation. Eligibility cannot be determined by the review of existing
data.
Evaluation Plan
Autism
Multiple Disabilities
Deaf-Blindness
Orthopedic Impairment
Deafness
Other Health Impairment
Developmental Delay
Specific Learning Disability
Emotional Disabiity
Speech or Language Impairment
Hearing Impairment
Traumatic Brain Injury
Intellectual Disability
Visual Impairment (including Blindness)
Special Education Referral: Preschool
C: EC File, Parent/Guardian Student UID#:
_______________________
Screening(s)/Evaluation(s)
Adaptive Behavior
Medical Evaluation
Progress Monitoring
Audiological
Motor Screening
Psychological
Braille Skills Inventory
Learning Media Assessment
Motor Evaluation
Social/Developmental History
Functional Vision
Assessment
Observation
Speech-Language Screening
Educational Evaluation
Opthalmological/Optometric
Speech Language/Communication
Evaluation
Health Screening
Otological
Vocational
Other:
Other:
Other:
*Summary of Conference(s)
with Parents
*Review of Existing Data
*Review of RtI Documentation of
Problem-Solving
* Required but does not require parental consent.
Complete the Consent for an Initial Evaluation.
V. IEP Team Participants
The following individuals were present and participated in the referral to special education and
IEP Team decision. (A Request to Excuse Required IEP Team Member(s) has been obtained if any of the below
participants are identified as excused. Note with an * any team member who used alternative means to participate.)
Name
Position
Date
Parent/Guardian/Student
Parent/Guardian/Student
LEA Representative
Special Education Teacher
General Education Teacher
Interpreter of Instructional
Implications of Evaluations
Provide a copy of the Prior Written Notice, Special Education Referral and Parents Rights and
Responsibilities in Special Education: Notice of Procedural Safeguards to the parent.
A copy was given/sent to the parents on: ____/____/____
Procedural Safeguard: Initial Evaluation Timeline
Using the date of the receipt of the written special education referral, the 90-day (calendar)
timeline for conducting the evaluations on the evaluation plan, determining eligibility, developing
an IEP for an eligible child and obtaining the Parent Consent for the Initial Provision of Services
is due on or before: ____/____/____.