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Behavior and Autism Consultation
This form is to be completed by DISTRICT EMPLOYEES ONLY.
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* Indicates required question
Name of Person Submitting the Request
*
Your answer
Name and Email for Contact Person
*
Your answer
Student Name
*
Your answer
Student Date of Birth
MM
/
DD
/
YYYY
Student Grade
*
Choose
ECE
K
1
2
3
4
5
6
7
8
9
10
11
12
Transition
Self-Contained with Mixed Grades
Student's School
*
Your answer
Student's Home District
*
Choose
LADSE Multi-District/CD
53
61
62
92.5
94
95
96
101
102
103
105
106
107
204
208
DHH
Has the district administrator or Special Education coordinator for the student been informed of this request?
*
Yes
No
Has the family of the student been informed of this request?
*
Yes
No
Consultation Requested to Support:
*
Communication supports
Aggressive behavior
Academic and/or Curriculum and classroom/program supports
Increasing student engagement
Other:
Required
What is the student’s current support?
*
Choose
IEP
504
Eligibility In Process
General Education
Other
What is the student’s current eligibility?
*
Your answer
Are you requesting support in relation to any of the following:
*
FBA/BIP
Inital IEP
IEP Re-evaluation
Placement
Classroom Management
None apply
Required
Meeting days and times that work best
Your answer
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