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Lisbon School Department
Office of Student Services
REFERRAL BY PARENT TO THE IEP TEAM
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REFERRAL INFORMATION
Date of referral: ______Date received (office use only): ______
Student’s name:______Date of birth:______
Parent name: ______
Address: ______Phone: ______
School:______Grade:______
Form filled out by:______Phone: ______
Relationship to student:______
Please explain the reasons for this referral. What concerns do you have about your child? Please describe the gap between the demands of the educational setting and the child’s current academic or functional performance:
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When did these difficulties start?______
What intervention activities, related to the gap, have been undertaken for the student in addition to the school program? For example, interventions might include supplemental reading and math instruction with Title I teachers, or a behavior management plan.
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Did you receive information about your child’s progress in supplementary instruction? If so, did your child make satisfactory progress?
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Are there any additional concerns you have about your child?
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Have you spoken with anyone at school about your concerns?______
If so, who and when?______
Does your child know you have requested an evaluation? ______If yes, what was his/her reaction?
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If not, do you plan to discuss the evaluation with him/her before it happens?_____
What information do you wish to gain from this evaluation?
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What are your child’s strengths and weaknesses, both in school and out of school? Please include any special talents or abilities:______
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What else do we need to know about your child before evaluating him/her?
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Please check each area in which you think your child needs individual evaluations:
___speech/language
__ intelligence
__academic achievement
__emotional/behavioral
__learning processes
Please check any below that apply to your child:
__vision problems
__wears glasses
__hearing problems
__wears hearing aids
__frequent ear infections?
Medical problems, surgeries, illnesses, medical treatments, medications?
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Family stressors?______
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Emotional difficulties?______
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Drug and alcohol use?______
Hyperactivity, inattention, distractibility?______
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Social difficulties?______
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Aggressive behavior such as fighting or violent outbursts?______
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Sadness or depression?______
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To your knowledge, have any of the following strategies been attempted with your child during the school year?
__ individual help from teacher, ed tech, or peers?
Modifications in any areas below?
__seating__grouping__assignments__testing
__materials__instructional presentation__discipline__schedule or routine
Reductions in any areas below?
__amount of class work__amount of homework
Is there a behavior management plan in place? _____ If yes, please check the components that are part of it:
__positive reinforcements
__time outs
__daily charts to go home
__assignment sheets?
__other:______
Have there been conferences with student and
__principal__ teachers__guidance counselor__ social worker__special education staff __other:______
Other strategies attempted to address problems and concerns?
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Why were they not successful?______
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Thank you for your input. Please sign below before returning this form.
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Parent signatureDate
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Special services director’s signatureDate received
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