Early Childhood Referral For Multidisciplinary Team (Snap) Evaluation printable pdf download

Date Written Notice

SOUTH BEND COMMUNITY SCHOOL CORPORATION

rec’d by certified

Special Education Services

personnel

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

574-283-8130; Fax 574-283-8105

____________

EARLY CHILDHOOD REFERRAL FOR MULTIDISCIPLINARY TEAM (SNAP) EVALUATION

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

Notice stating that they propose or refuse to conduct the evaluation. At that time, parental consent for the

evaluation may be sought

**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.

*FOR OFFICE USE ONLY*



Date rec’d-certified personnel: __________________________________

First Steps Referral? Yes

Was SBCSC invited to transition?



If yes, Service Coordinator?

Yes

50 instructional days: _________________________________________

__________________________

Did SBCSC attended transition?



45 instructional days: _________________________________________

Yes



Transition on time? Yes

Rec’d in office: _______________________________________________

Assigned to: ________________________________________________

*Parent requests meeting five (5) days prior: Yes  No 

Date of Meeting w/Psych: _____________________________________

Child ______________________________________________ Birth Date __________ Age ______ Sex  M  F

Ethnic Code: (check all that apply):

 Am. Indian  African American  Asian  Hispanic  White  Multiracial  Hawaiian/Pacific Islander

PARENT SURVEY

Name of person providing information: ______________________________________________________________

Relationship to child:  Parent  Foster Parent  Legal Guardian

Family Information

Who is the primary guardian(s) adult(s) who takes full legal responsibility for this child?

Name: __________________________________________ Relation to child: ______________________________

Age: ________ Education: _________________________ Address: _____________________________________

Phone: __________________________ email: ________________________________________________________

Does the child live with this person?  No  Yes

SNAP Evaluation Referral

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Early Childhood Referral For Multidisciplinary Team (Snap) Evaluation

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