Referral For Initial Multidisciplinary Team Evaluation (50 Day Timeline)
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8Date Written Notice
SOUTH BEND COMMUNITY SCHOOL CORPORATION
rec’d by certified
personnel
Special Education Services
____________
215 South St. Joseph St., South Bend, IN 46601
574-283-8130; Fax 574-283-8105
REFERRAL FOR INITIAL MULTIDISCIPLINARY TEAM EVALUATION (50 day timeline)
All Grades
The referral for multidisciplinary team evaluation may be initiated by a parent/guardian or by school/public
agency personnel. If a parent makes a request, the school has 10 instructional days to provide the parent with
Written Notice stating that they propose or refuse to conduct the evaluation. At that time, parental consent for
the evaluation may be sought. All referrals must be screened by school personnel for completeness.
Incomplete referrals will be returned to obtain necessary information.
**The case conference committee meeting has been scheduled for:
(Date)_________________ (Time)_____________________(Location)______________________
**This conference must be scheduled at the time of this referral. Be sure to inform all CC members
immediately. A formal Notice of Case Conference must still be sent prior to the scheduled CC.
This referral has been reviewed for completeness: _____________________________________________
Principal Signature required
*FOR OFFICE USE ONLY*
Date rec’d-certified personnel: _________________________________
Attachments
Gen. Ed. Intervention Team Forms
50 instructional days: ________________________________________
Outside psych. Evaluation
45 instructional days: ________________________________________
Academic Record/Test Record
Rec’d in office: ____________________________________________
Assigned to: _______________________________________________
*Parent requests meeting five (5) days prior: Yes No
Date of Meeting w/Psych: ____________________________________
Student _______________________________________________ Birth Date _____________ Age _____
Student ID # _____________ STN# __________________ Ethnic Code ______________ Sex M F
Parent/Guardian Name _____________________________________________________________________
Street Address ______________________________ City _______________________ Zip ___________
Mother’s home phone _________________________ Father’s home phone __________________________
Mother’s cell phone __________________________ Father’s cell phone ___________________________
Mother’s email address ________________________ Father’s email address _________________________
School (attending) ____________________________ Home School (if different) ______________________
If private/parochial school, provide school’s address _______________________________ Zip __________
Phone # _____________________
Teacher ___________________________________________ Grade _________ Home Room No. ______
Referral Source: Parent School/Agency
Contact person’s email ___________________________
Date of Referral ___________________
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EFERRAL FOR
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