EMAIL completed referral form to

or fax to (859) 442-7038 Attn. Karen Bowling

NORTHERN KENTUCKY COOPERATIVE FOR EDUCATIONAL SERVICES

Referral for NKCES Individual Services

Identifying Information

Student’s Name / Date of Birth / C.A.
School District / School / Grade
School Contact Person / Title
Phone / Planning Period/Best Time to Contact
Parent/Guardian / (include last name) / Home Address / Number Street
City
Home Phone / Work Phone / Other Contact Number

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EVALUATIONS/SERVICES REQUESTED

(Please check service requested AND complete page 2 of referral.)

Diagnostic and/or Consultative Services

Assistive Technology Evaluation
The AT referral MUST accompany this form. / Instructional Strategies/Curricular Modifications: specify content area(s):
Audiological Evaluation / Literacy Strategies (NKCES staff)
Autism Evaluation/Consultation (NKCES staff) / Ophthalmological Evaluation
Behavior Observation/Consultation (NKCES staff) / Psychiatric Evaluation
CCDDD Evaluation: specify area: / Psychological Evaluation
Behavior Observation/Consult during evaluation / Complex Needs (Severe/Profound) Eval (NKCES staff)
Complex Needs Observation/Consult during evaluation / Speech/Language Evaluation
Classroom Environmental Audit (NKCES staff) / Teacher and/or Staff Consultation(NKCES staff)
Counseling: specify agency: / UDL/Read & Write/Wordsmith (NKCES staff)
Consultation w/Regional Staff: KSD KSB D/B / Referral to KSD program housed at Kenton Co.
Developmental Pediatric Evaluation / PD for school/district staff:
Technical Assistance: KCMP Other / ARC attendance: Due Process Other
Research: Due process issues or other: specify / Other: specify

The Admission and Release Committee has determined that the above services are necessary.

Director of Special Education Signature Date

Parent Permission Required for Referral to Outside Agencies ONLY (not for NKCES staff)

This is to indicate that I have been informed and counseled regarding the referral of my child for individual services (checked above) as determined by personnel of the school district named and in cooperation with the Northern Kentucky Cooperative for Educational Services (NKCES).

I give my permission for such services, consent for Director or designee from referring School district to attend informing interview, and release of related reports to NKCES and the referring School district.

I will make every effort to keep all scheduled appointments.

Parent Signature ______*Date ______

*Parent permission is valid for one (1) year after date signed.

NORTHERN KENTUCKY COOPERATIVE FOR EDUCATIONAL SERVICES

Referral for NKCES Individual Services

Student’s Name / Date of Birth
Reason for Referral (please be specific)
Behavior Observation/Consultation - when do these behaviors occur (i.e. A.M., P.M., lunch, specific class, etc.)
Please list specific questions you want answered concerning this case.

Current Placement:

Regular / Grade
Special Placement (specify) / Dates
Remedial reading / Dates
Speech Therapy / Dates
Other (specify) / Dates

Student’s Schedule

What previous strategies have been utilized in this case?

Educational Assessment Data:

Test Name / Date Administered / Result

Please attach additional information (evaluations, reports, documentation, teacher observations, and comments)

Known Physical Problems: (Check means yes)

Vision / Health Impairments
Hearing / Other Physical Disabilities

Is child on medication? (Give type and reason)

Is child receiving medical treatment? (specify - Include Doctor(s) name)

Is child receiving psychological/psychiatric treatment? (specify - Include Doctor(s) name)

Is insurance available to cover this service? (specify)

Name of Company/Agency Policy or ID Number

Address of Company/Agency

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