Medical Referral For Students With Orthopedic Impairments, Traumatic Brain Injury, Or Other Health Impairments printable pdf download

Medical Referral For Students With Orthopedic Impairments, Traumatic Brain Injury, Or Other Health Impairments

South Bend Community School Corporation

Special Education Department

215 S. St. Joseph St, South Bend, IN 46601

Ph: 574.283.8130 Fax: 574.283.810

Medical Referral for Students with Orthopedic impairments, Traumatic

Brain Injury, or Other Health Impairments

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

School: _______________________________ DOB: _____________________ Date: _____________________

TO THE PHYSICIAN:

The South Bend Community School Corporation provides special education and related services to students who

qualify for special education under federal and state law.

A medical referral has been initiated for the above named student. Establishment of eligibility for services under

one of these disabilities is made by the case conference committee. The services which are needed are identified

in an Individual Education Plan (IEP).

We are required to have the written diagnostic statement on file. Please complete the information as indicated

and return the form to the address above. If you have any questions, please contact the Special Education

Department at 574-283-8130.

It is very important to complete the information below to assist in the educational planning for the above named

student.

Medical Diagnosis: ____________________________________________________________________________

Traumatic Brain Injury (Please describe the extent of the injury): ________________________________________

___________________________________________________________________________________________

Comments/Concerns: _________________________________________________________________________

___________________________________________________________________________________________

Educational Implications: _______________________________________________________________________

___________________________________________________________________________________________

Physician Name: _____________________________________________________________________________

(Please Print)

(Signature)

Physician Address: ___________________________________________________________________________

___________________________________________________________________________________________

Phone: ______________________________

Date: ________________________________

8/6/10

Medical Referral For Students With Orthopedic Impairments, Traumatic Brain Injury, Or Other Health Impairments