This form is to be used to initiate the review of a student’s progress and any developmental, academic, or school problems. Please submit the completed form to the principal of the student’s school or the child's school attendance area school. Following a review by the school child study team, you will be informed of its disposition.

Instructions for Parents completing this form:
Parents, please complete sections 1, 2, and 3. This referral will be reviewed to determine need for evaluation. Parents will be informed and asked to give their written consent before an evaluation is initiated or a change in program is made.

Instructions for other Service Providers completing this form:
School, Health Services, Head Start, and/or Other Agency Personnel, please complete sections 1, 2, and 3. As appropriate complete and attach the Screening Information Form (SE-2).