Referral For Initial Multidisciplinary Team Evaluation (50 Day Timeline) Form

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SOUTH BEND COMMUNITY SCHOOL CORPORATION
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)
Parent/Guardian Portion
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
Date ________________________________________
Student’s Name ______________________________
School __________________________________
Name of person providing information _________________________________________________________
Relationship to student _____________________________________________________________________
Family Information
Mother's name
Age
Education _______________
Address _________________________________________________________________________________
Employer
Phone: Home
Work _________ Cell __________
Father's name
Age
Education _______________
Address _________________________________________________________________________________
Employer
Phone: Home
Work _________ Cell __________
Stepparent's name
Age
Education ________________
Address _________________________________________________________________________________
Employer
Phone: Home
Work _________Cell ___________
Marital status of parents _____________________________________________________________________
If parents are separated or divorced, how old was the child when the separation occurred? _________________
Does the child see the non-custodial parent?
Yes _____ No ______If yes, how often?___________________
Is child adopted? Yes___ No___ If yes, at what age? ______ Does child know of adoption? Yes____ No____
Has the child been in foster care? ____Yes ____No If yes, when? __________ with whom?_______________
_________________________________________________________________________________________
List all people living in household
Name
Relationship to Child
Age
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If any brothers or sisters are living outside the home, list their names and ages ___________________________
__________________________________________________________________________________________
Primary language spoken at home
Other languages spoken at home _______________
Is there a history of learning and/or behavioral problems in the family? Yes ______ No _______
If yes, list family member(s) and describe ___________________________________________________
____________________________________________________________________________________
Rev. 6/12

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