Sample Referral letter

Sample Referral for Special Education Evaluations [DATE] [For students who are in preschool, private school or are not enrolled] [CHAIRPERSON] [Committee on Special Education #____] [ADDRESS] [OR for students who attend public school] [SCHOOL PSYCHOLOGIST] [SCHOOL NAME] [ADDRESS] RE:

[NAME] DOB:______ NYC ID #: ___________________

Dear [NAME]: I am writing to request that my child [NAME] be evaluated for school age special education services. My child currently attends school at [P.S.___]. I have concerns because my child .... [For example, “is in 5th grade but is reading at a 2nd grade reading level” or “has trouble pronouncing words.”] My child’s teacher has mentioned to me that.... [For example, “my child needs individualized attention to learn new concepts” or “is constantly out of his/her seat and unable to focus.”] Specifically, I request that [NAME] receive a psycho-educational evaluation, social history and [OCCUPATIONAL THERAPY/PHYSICAL THERAPY/ SPEECH & LANGUAGE EVALUATION, ETC]. Please contact me at the following address to arrange for evaluations: [ADDRESS AND PHONE] I also ask that the Committee on Special Education convene a meeting to review my child’s case as soon as the requested evaluations are complete. Please contact me at [NUMBER] to schedule the review meeting. Sincerely, [NAME] Parent