Referral For Initial Multidisciplinary Team Evaluation (50 Day Timeline) Form
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5SOUTH BEND COMMUNITY SCHOOL CORPORATION
Date Received
Special Education Services
by Psych
215 South St. Joseph St., South Bend, IN 46601
_____________
Tel: (574) 283-8130; Fax: (574) 283-8105
REFERRAL FOR INITIAL MULTIDISCIPLINARY TEAM EVALUATION (50 day timeline)
Parent/Guardian Survey
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.
Date: _________________ S tudent Name: __________________________________ School: ___________________
Name of person providing information: _______________________________________________________________
Relationship to student: o Parent o Foster Parent o Legal Guardian o Relative
Primary language spoken at home _ _______________________ List other languages spoken _ __________________
Reason for Evaluation o Academic Problems o Behavior/Emotional Problems o Don’t know
FAMILY INFORMATION
Who is the primary guardian (adult who takes full legal responsibility) for this child?
Name: _ _________________________________________________ Relation to child: ________________________
Age: ________ Education: _____________________ Address: _ _________________________________________
Phone: ____________________ email: ________________________ Does the child live with this person? o No o Yes
Marital Status of Guardian(s) o Single o Married o Divorced/Separated o Widowed
If the Child also lives/spends time at another residence other than the primary guardian, please indicate
Name: _ _________________________________ Relation to child: _ _____________________________
If there are any other adults who live with the child, please indicate below
N
R
AME
ELATION TO PRIMARY GUARDIAN
_______________________________ __________________________________
_______________________________ __________________________________
Children who live with the child
N
R
C
A
AME
ELATION TO
HILD
GE
________________________________ o Sibling o half-sibling o other
_________________ _ _____
(specify)
________________________________ o Sibling o half-sibling o other
_________________ _ _____
(specify)
________________________________ o Sibling o half-sibling o other
_________________ _ _____
(specify)
________________________________ o Sibling o half-sibling o other
_________________ _ _____
(specify)
If parents are separated or divorced, how old was the child
If the child has been adopted at what age? _________
when the separation occurred? _ _____
Does the child know of the adoption? o No o Yes.
Does the child see the non-custodial parent? o No o Yes
If so, how often? _______________________________
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8/2016
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