Name of Student (last, first)
Name of teacher making referral
Reason for referral (check off all that apply)
Specific Learning Disability
Behavior (OHI ADHD, Emotional Disturbance)
Visual or hearing impairment
Is the student already receiving services through Special Education?
Is the referral due to a parent request?
If you answered "yes" make sure that parent's letter has been received by front office and approved by admin.
If this is a teacher request, please indicate date, time of conference with parent; in which you indicated that you would like to submit a request for a Special Education referral.
Was the student previously in RTI?
If the student was NOT previously in RTI, briefly explain why you did not initiate a referral to RTI.
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