Sample Referral School Request Form printable pdf download

Sample Referral School Request Form

Sample Letters

SAMPLE REFERRAL REQUEST

(Keep a copy of this letter for your records)

(Note: Could be sent to the Special Education Director, Principal, Contact Person or

Superintendent. Keep a copy for your records)

(Date)

Dear __________________

I am making a formal request for a complete educational evaluation for my child,

(Name of Child), who is a student at (name of school) in (grade/class).

I am making this request because I believe that my child may have educational

disabilities. (Make a brief listing, such as ADD, short attention span, vision problems,

speech or language problems, physical issues, failing most classes, inability to get

along with others, unsatisfactory performance on group achievement or accountability

measures, multiple behavioral or academic warnings, suspensions/expulsion from

childcare or after school programs, inability to progress or participate in

developmentally appropriate preschool activities, receiving services from Family-

Centered Early Supports and Services, etc.)

I understand that you will contact me in writing to set up a team meeting date so that

the team can make the necessary decisions about my concerns within 15 days.

Please let me know if I can provide any additional information to assist you in better

understanding (my child’s) needs. I look forward to hearing from you.

Sincerely,

(Your name, address, telephone number and email address)

cc: (List of other people to whom you are sending a copy of this letter)

For more information on the special education process, and upcoming workshop opportunities, please visit our

website at

. Be sure to read our brochure, “Steps in the NH Special Education Process”.

Sample Referral School Request Form