Please Complete the Application As Thoroughly As Possible. Submit the Application To

6/22/17

Educational Service Unit 7

Cen7ter Application

Please complete the application as thoroughly as possible. Submit the application to

DarusMettler, Cen7ter Administrator, Educational Service Unit 7 2563 44th Ave Columbus, NE 68601 or fax to 402-563-1121. Please call if you have questions

402-564-0815 ext 1060.

Contact Information

Name of school ______District ______

Name of person making the referral ______Phone # ______

Email______

Student Information

Student name ______Birth date ______Age______Grade ___Sex______

Parents’ name ______

Student lives with: ____parent ____ grandparent ____ foster parent ____ other

If the child is living with someone other than a parent, please list who has educational rights. ______

Educational Information

Date and category of initial verification ______

Date and category of most recent verification ______

Why are you considering a placement at Cen7ter?

Are the parents aware that Cen7ter placement is being considered? ______

Describe the student’s current placement. Include the setting, the curriculum that is used, the number of staff working with the student, and the time spent in special education services. How much of the time spent in the special education setting is direct instructional time from a resource teacher or speech/language pathologist?

What assistive technology are you currently using to help this child?

Have you discussed this student’s programming/needs with your school psychologist? _____ What recommendations were you given?

What attempts has your district made to serve this student in the past? (3 years or sinceenrollment in school?)

Setting Curriculum Modifications/Accommodations Duration Reason for change

Health information:

Is the student currently under the care of a physician for any condition? _____ If yes, what condition? ______

Has the student ever been under the care of a physician for emotional, behavioral, seizure disorders, genetic disorders, ADHD, childhood depression, etc.? ______If yes, please describe the condition and include medical reports that are in the child’s file. ______

Is the student currently taking any prescribed medications or herbal remedies? ____ If yes, please list the name, the dosage, and the purpose of the medication or herbal remedy. ______

Does this child wear glasses? ______Contacts? _____

Does this child have a hearing impairment? ______

Is the student independent with toileting needs? ______

What are the dietary restrictions? ______

Describe any behavior strategies used ______

Please attach the following documents to this referral form:

______Current IEP

______Current Evaluation, including those completed by agencies other than ESU 7

______Health records, including current medications, medical reports, hearing and vision

reports

______Grade report/most recent report card

______District assessment results

Superintendent Signature/Date ______

Cen7ter intake process

Complete Cen7ter application.

Cen7ter team reviews documents.

Representative from Cen7ter team observes the student at their home district.

Student (applicant) and parent tour Cen7ter.

Cen7ter team makes a recommendation to the home district teacher.

Home district invites Cen7ter representative to student’s IEP meeting to discuss student needs, goals, services and placement.