SOUTH BEND COMMUNITY SCHOOL CORPORATION

Special Education Services

215 South St.Joseph St., South Bend, IN 46601
574-283-8130

Date recd by
certified
personnel
____________

REFERRAL FOR RE-EVALUATION (Preschool)

All referrals must be screened by school personnel for completeness. Incomplete referrals will be returned to
obtain necessary information.
If required, the case conference is to be conducted within 50 instructional days of the date the written consent is
received by school personnel. See information on the Consent page to assist in determining the need for a case
conference within 50 school days. If required, please schedule a date/time below.
**The case conference committee meeting has been scheduled for:
(Date)_________________ (Time)_____________________(Location)______________________
**This conference must be scheduled at the time of this referral. Be sure to inform all CC members
immediately. A formal Notice of Case Conference must still be sent prior to the scheduled CC.
This referral has been reviewed for completeness: _____________________________________________
Designee Signature required
*FOR OFFICE USE ONLY*
Sections Complete:
I
II
III___IV

Date recd-certified personnel:

50 instructional days:__________________

Attachments
___ __________________________
___ Academic Record/Test Record
Recd in office:_______________________
Assigned to: _________________________________

Student
Birth Date
Age ________
Student ID #_____________ STN# ______________________ Ethnic Code ___________ Sex: M F
Parent/Guardian Name _____________________________________________________________________
Street Address ___________________________________________________________________________
City
State
Zip
Phone ______________
School (Attending)
Home School (if different)____________________________
If in a community preschool, provide schools address ________________________________ Zip _________
Phone # __________________
Days/times in attendance _____________________________
Teacher___________________________________ Referral Source ____________________________
(Full Name)
(Name and title)
Rev. 9/09

Referral for Re-Evaluation (Preschool)

Students Name: ______________________________

2
School: ________________________________

REASON FOR REFERRAL:

Current Primary eligibility _____________________
Current Secondary eligibility(ies) _______________________________________________________
Check one of the following three options:
Option 1
________ I suspect that the student is no longer eligible for special education services under the category of
__________________________________
Option 2
_______
_______
Option 3
______

I suspect a change in the students eligibility from _______________ to _____________________

I suspect an additional eligibility area of ______________________________________________
Information is needed to inform the case conference committee of the students special education
and related services needs (describe: _________________________________________________)

SPEECH-LANGUAGE PATHOLOGISTS REPORT (IF APPLICABLE)

To be completed if student receives speech/language therapy but there is no need for updated speech/language
evaluation
Name of Speech-Language Pathologist_________________________________________________________
Therapy began______________________ Frequency/Duration of therapy_____________________________
Test results:________________________________________________________________________________
__________________________________________________________________________________________
Current goals:______________________________________________________________________________
_________________________________________________________________________________________
Describe behavior during therapy: ______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________
DATE

______________________________________________
SIGNATURE OF SLP

Referral for Re-Evaluation (Preschool)

RETURN TO PSYCHOLOGIST BY
_______________________
CLASSROOM TEACHER COMPLETES THIS SECTION
Students Name: ______________________________

School: _______________________________

Describe the childs strengths:

Describe your concerns about the childs development or behavior:

Describe the childs present skill levels:

How does the child interact with other children in the class?

What activities or items are motivating or reinforcing to the child?

Does the student exhibit any unusual or atypical behaviors? Yes ____ No _____ If yes, describe: __________
Does the student have a Behavioral Intervention Plan? Yes _________ No _________
If yes, attach a copy.
If referred for behavioral reasons, provide detailed documentation of behavioral interventions.
Summarize current special education services, including related services:
__________________________________________________________________________________________
_________________________________________________________________________________________
__________________________
DATE

____________________________________________________________
SIGNATURE OF TEACHER