Referral For Re-Evaluation (Grades 7-12) Page 2
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3Student’s Name: ______________________________
School: ________________________________
REASON FOR REFERRAL:
Current Primary eligibility _____________________
Current Secondary eligibility(ies) _______________________________________________________
Check one of the following three options:
Option 1
________ There is a need to re-establish the student’s eligibility of __________________________________
because (check one):
_________It is suspected that the student is no longer eligible for special
education/related services.
_________ It is suspected that the student’s disability is no longer adversely affecting
his/her educational/functional performance.
_________ Student moved in from out of state and records are not available.
_________ Other (describe): _____________________________________________
Option 2
_______
There is a suspected change in the student=s eligibility from _______________ to
______________
_______
There is a suspected additional eligibility area of ________________________________________
Option 3
______
Information is needed to inform the case conference committee of the student’s special education
and related services needs (describe: _________________________________________________)
THE REASONS FOR THIS RE-EVALUATION REQUEST MUST BE PROVIDED ON THE IEP WORKSHEET,
WHICH IS TO BE ATTACHED TO THIS REFERRAL.
SPEECH-LANGUAGE PATHOLOGIST=S REPORT (IF APPLICABLE)
To be completed if student receives speech/language therapy but there is no need for updated speech/language
evaluation
Name of Speech-language Pathologist___________________________________________________________
Therapy began________________________Frequency/Duration of therapy_____________________________
Test results:________________________________________________________________________________
__________________________________________________________________________________________
Current goals:______________________________________________________________________________
_________________________________________________________________________________________
Describe behavior during therapy: ______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_____________________
______________________________________________
DATE
SIGNATURE OF SLP
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