Referral For Communication And Assistive Technology Evaluation

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South Bend Community School Corporation
Special Education Services
Referral for Communication and Assistive Technology Evaluation
Student: _______________________________________ School: _____________________ Phone: _______________
SBCSC ID#: _________________STN: ______________________ DOB: ______________ Grade: ________________
TOR: _________________________________________________ Phone: ___________________________________
TOS: _________________________________________________ Phone: ___________________________________
This referral may only be generated as a result of a case conference decision for a Reevaluation
requesting to “inform the student’s case conference committee of the student’s special education
and related service needs.”
Date of IEP requesting reevaluation: ______________________
Describe what you want this student to be able to do with Assistive Technology.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Describe accommodations/technology that you have already tried or are currently using with this student.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Check the curriculum areas you would like to have considered in this Assistive Technology evaluation (Check
all that apply):
_____Reading
_____Writing
_____Math
_____Expressive Language
_____Receptive Language
_____Spelling
_____Study Skills
_____Homework Completion
_____Transition
Has this student been referred for a CAT evaluation in the past?__________________________________
When?_______________________________________________________________________________
Upon completion of this form, please attach:
_____ the most current IEP (including Case Conference Notes)
_____ the most recent M-Team evaluation
Send to Edison Intermediate Center addressed to the CAT Team
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