SAMPLE REFERRAL REQUEST

(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, 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)