District Quicklinks

Referral Forms
 

For all referral forms, please complete each section and question to the best of your abilities.
The information is very important in the process.  All of the information is included when planning and writing a student’s evaluation report.

 
FORMS

DESCRIPTION

KEY POINTS

Child Study Referral Form

Initial Referral Cover Sheet

The Child Study Referral Form is used by the general education teacher and the child study team to document areas of concerns, strengths, interventions, and data collection as part of their referral for a special education evaluation.

The Initial Referral Cover Sheet is attached to the front of the Child Study Referral Form when sections A through E are faxed or emailed to the School Psychologist office to start the special education evaluation process.

 

 

DD to Categorical Referral Form

The Development Delay (DD) to Categorical Referral Form is used by the Early Childhood Special Education (ECSE) or current case manager (sometimes elementary special education teacher) to fill out approximately 90 days prior to the student’s 7th birthday if the team determines the student has not met their goals and may meet eligibility for a categorical placement for continued special education services.

 

The ECSE teacher needs to be invited to the evaluation planning meeting and evaluation results meeting.

If the team determines a student has met their goals and no longer need services, the ECSE teacher is responsible for completing an exit evaluation prior to the student's 7th birthday.


 

Re-evaluation Referral Form

The Re-evaluation Referral Form is completed by a student’s case manager approximately 90 days prior to 3 years from the student’s last evaluation. It documents current concerns, grades, and strengths

 

If trying to meet an IEP date, please send the referral approximately 90 days before the annual IEP date.

Out of State Referral Form

The Out of State Referral Form is completed by the assigned case manager when a student moves into the state of MN on an IEP from another state or Country

Please begin an interim IEP based on information from the Out of State IEP. Contact your building coordinator and/or psychologist(s) to determine how soon you can proceed with an initial evaluation for determining MN eligibility.