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Special Populations Referral
Please complete this form for any student you would like to refer for a special education or 504 evaluation. The LEA’s responsibility for child find is for all children with disabilities ages 0-21. The LEA is responsible for identifying, locating, and evaluating all children with disabilities who need special education and related services. 
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Email *
If the referral is being made by someone other than the parent, has the parent been contacted to discuss possible concerns? (Telephone, Parent Conference, E-Mail, etc.) *
Referred by:                                             *
This referral is being made by: ___________________________
Student's Name *
Campus *
Student's Grade Level *
Please give a brief description/summary for a special education evaluation. Please include specific examples of areas of concern such as student progress, behavior-list specific behaviors, and/or speech concerns. Please also include any supports that have been made to try and support this student in the general education classroom setting. *
Phone Contact-Person making the referral. *
E-Mail-Person making the referral. *
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