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Speech/language Enrollment Form

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South Bend Community School Corporation

Special Education Department

Speech/Language Enrollment Form

Date: ___________________

Student Name: __________________________ SBCSC ID#: ______________ STN#: ____________________

Sex: _____________ Date of Birth: ___________________________________ Grade:____________________

Ethnic Code: _______________________ School Attending: _________________________________________

Home/Resident SBCSC School (for Non Public Schools also): ________________________________________

Parent’s Name: _________________________________________ Phone: _____________________________

Address: _______________________________________ City: _____________________ Zip: _____________

SLP: ______________________________ Consultation:___________ Direct: ___________ %= _____________

Check One or Both:

Language Impairment

Speech Impairment

Primary Disability (if not LI or SI):________________________ TOR for Primary: _________________________

Add

Dismiss as Corrected

Withdrawn (Date: ______________)

Transferred to another SBCSC School: ____________________

Moved out of SBCSC

Referral Source:

Parent

School

Other: ______________________________________

Date of Referral: _____________________ Date of Written Notice: ___________________________________

Date of Permission to Test: ____________________ Date of Evaluation: ______________________________

Date of Case Conference: _____________________ Date Therapy Started (week of): ____________________

Disposition:

Enrolled

Not Eligible

No Show

Decline Permission

Move

_________________________________________________________________________________________

Complete for Preschool Students (Information required by the State)

Please Check:

Speech Only

Power Hour

Consult

Transportation Needed

Least Restrictive Environment (LRE Type): _______________________________________________________

Referral Source: ____________________________________________________________________________

If First Steps Referral:

Service Coordinator: _______________________________Was there a transition Conference? _____________

SBCSC Rep was invited to Transition Conference w/ 10 day Notice ____________________________________

SBCSC Rep attended Transition Conference? ____________

Was IEP implemented by 3

birthday? _____________ If No, late because: _____________________________

Explanation if needed: _______________________________________________________________________

Return completed form to the Special Education Office to Add/Delete Student from Caseload

6/11/2015

Speech/language Enrollment Form

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