Student Education Specialist Form

Student Education Specialist Form

Student Information

Student Name:    Date of Birth:

Student ID:    Grade / Program:

Parent / Guardian Information

Referral Details

Referral Date:    Referred By:

Primary Reason for Referral (check all that apply)

Academic concerns (progress, skills)
Behavioral concerns (in-class behavior)
Social/emotional concerns
Attendance / engagement
Other (specify below)

Academic and Behavioral History

Brief description of the student's current academic performance, behavior, and known diagnoses or accommodations:

Interventions Previously Attempted

Indicate supports already implemented (check all that apply):

In-class differentiation
Small group instruction
Behavior plan / BIP
Counseling services
Classroom accommodations (IEP/504)
None documented

Assessment / Screening Requests

Requested screening or assessment areas (check all that apply):

Reading / literacy screening
Math skills screening
Behavioral / social-emotional screening
Speech / language evaluation
Occupational therapy screening
Physical therapy screening

Requested timeline for assessment:

Parent/Guardian consents to release of educational records and to conduct the requested assessments: I consent    If not consenting, explain:

Recommended Services and Goals

Recommended services, frequency, and anticipated goals (to be completed by Education Specialist where applicable):

Confidentiality and Release

By submitting this form, the undersigned authorizes the exchange of relevant educational and health records between the school, Education Specialist, and contracted providers to the extent necessary to evaluate and provide recommended services. Records will be maintained in accordance with applicable privacy laws and district policy. This authorization is limited to information reasonably related to the requested assessment or services and expires on the date services are completed unless otherwise specified below.

Administrative Use Only

Initial Review Date:    Start Date of Services:    End Date of Services:

Certification and Acknowledgment

I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand that submission of this form initiates school-based review and potential assessment and does not by itself constitute eligibility for special education or related services. I understand that I may withdraw consent in writing at any time and that certain records will be maintained in the student's educational file as required by law.

If signing as a parent or guardian, I attest that I have authority to consent for the student named above. If signing as an adult student, I attest that I am the student named above and authorize the requested services.

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