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.

Students and families: ALC referrals must be made by a school district. School districts, please reach out to the Northland Learning Center for referral link.

English Language Learner Resources: Is it ESL/ELL and not SLD? This includes strategies for Tiered Intervention

Reducing Bias: African American & American Indian Students





Updated 9/21/23 MTSS/SST Forms


Initial Referral 
Download and save the form, then complete and attach to an email to the school psychologist. The form could also be printed out if needed.


Did the school nurse screen vision and hearing before starting interventions?

ASD related concerns? Complete the Common Characteristics Checklist and contact school psychologist to do observation before starting interventions.

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.

Flow Chart for Special Education Reevaluation Determination

Three Year Reevaluation Waiver Consideration Form

When a team is considering whether or not a re-evaluation is needed, the Three Year Reevaluation Waiver Consideration Form is completed by the case manager with input from the IEP Team. 
Submit the form to your Coordinator/Assistant Director for review.