Request for SECEP Services
Program
ACP = Autistic Children’s Program
EBICS = Education and Behavioral Interventions for Challenging Students
Re-ED = Re-education for students with Emotional Disabilities
TRAEP (students with IEPs only) = Tidewater Regional Alternative Education Program
Service
Record Review *(Re-ED/TRAEP) or Record Review and Observation *(ACP/EBICS)
Follow-up Services on Reintegrated Student (ACP/EBICS/Re-ED)
Student Demographics
Name:
DOB:
Student Division ID:
Student Testing ID:
Division: Suffolk Public Schools
Categorical ID: Primary- Secondary- Tertiary-
Date Request Sent:
School Contact Person:
Telephone Number:
Prior Written Notice has been given to the Parent and Parental consent has been obtained for a records review/release and for ACP/EBICS programs, consent for observation.
LEA Authorized Signature: ______
The following records need to be included in the Parental consent for Review/Release obtained by the division. These records will need to be provided to SECEP for any student whose IEP team places the student in a SECEP program PRIOR to the student’s enrollment with SECEP:
· Current IEP
· Manifestation Minutes
· Evaluation Reports to include:
o Educational
o Psychological
o Medical
o Psychiatric
o Social History
o Related Services
· Most Recent Eligibility/Triennial Minutes
· FBA/BIP
· Transcripts and current grades
· Alternative Assessment Results
· Current Alternative Assessment Collection of Evidence and documentation
· SOL Scores
· Discipline Information
· Current Health Record
Revised 9/2009
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