SOESD Request for Student Services
The purpose of this form is to request or discontinue Regional lnclusive Services or specific special education services offered by SOESD.
Student
Information
Reason for
Referral
Request
Information
Attach
Files
Review and
Submit
Student Information
Student's Full Legal Name:
First
*
MI
Last
*
Student Also Known As:
Grade
*
Birth-3
3-5
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Transition
Date of Birth
*
Age
Student Primary Language
*
Arabic
Chinese Traditional
Chinese Simplified
English
Russian
Sign Language
Somali
Spanish
Vietnamese
Sign Language
Other
Attending District
*
{{district.name}}
Resident District
*
{{district.name}}
Attending school
*
Resident School
Teacher's name
Current IEP/IFSP
*
Yes
No
504 Plan
*
Yes
No
Current Disability Code(s)
Select all that apply
10 Intellectual Disability (ID)
20 Deaf or Hard of Hearing (DHH)
40 Visual Impairment (VI)
43 Deafblindness (DB)
50 Speech and Language Impairment
60 Emotional Behavior Disability (EBD)
70 Orthopedic Impairment (OI)
74 Traumatic Brain Injury (TBI)
80 Other Health Impairment (OHI)
82 Autism Spectrum Disorder (ASD)
90 Specific Learning Disability (SLD)
96 Developmental Delay EI - Age Birth-2 years (DD)
98 Developmental Delay Age 3-9 years (DD)
Student's Medical/Health Conditions and Current Health Protocols
Parent/Legal Guardian Name(s)
*
Primary Language of Parent/Guardian
*
Arabic
Chinese Traditional
Chinese Simplified
English
Russian
Sign Language
Somali
Spanish
Vietnamese
Sign Language
Other
Parent/Guardian requires translator
No
Yes
Parent/Guardian Phone
*
Text OK?
Yes
No
Home Phone
Work Phone
Parent/Guardian Email
Parent/Legal Guardian Physical Address
*
Address
City
State
Zip
Parent/Legal Guardian Mailing Address
*
Same as Physical Address
Address
City
State
Zip
Person Requesting Service
*
Requester Title
*
Requester District
*
{{district.name}}
Requester School
*
Requester's Phone Number
*
Requester's Email Address
*
Continue
Reason(s) For Referral (areas of concern)
What services do you need?
*
Pre Referral Service
One time observations, screenings, observations, and other pre referral services.
Student Evaluation
Service for Regionally Eligible Student
Service for Non-Regional Student
STEPS Program Services
Regional Services Withdrawn/Discontinued
Continue
Request Information
Please select a reason for referral in previous section.
Pre Referral Service
Please select service(s) you need from below
*
One time observations, screenings, observations, and other pre referral services
One time observation
Screenings
Observations
Other
Please name other service(s)
Student Evaluation
Please select service(s) you need evaluations from below
*
Autism
Deaf/Hard of Hearing
Occupational Therapy
Physical Therapy
Vision
Psychology
Speech and Language
Nursing
Other
Please name other department(s)
Service for Regionally Eligible Student
Please select services for regionally eligible student needs below
*
Autism Spectrum Disorder (82)
Deaf/Hard of Hearing (20)
Deafblind (43)
Orthopedic Impairment (70)
Select One
Occupational Therapy
Physical therapy
Traumatic Brain Injury (74)
Vision Impairment (40)
Service for Non-Regional Student
Please select services for non-Regionally eligible student needs below
*
Autism Spectrum Disorder
Deaf/Hard of Hearing
Deafblind
Orthopedic Impairment
Select One
Occupational Therapy
Physical therapy
Traumatic Brain Injury
Vision Impairment
STEPS Program Services
Please select STEPS Program below
*
STEPS CARE Classroom - Elementary
STEPS CARE Classroom - Middle/HS + 18-21
STEPS Plus Classroom - (age 5-21)
Regional Services Withdrawn/Discontinued
Please select services being discontinued
*
Autism Spectrum Disorder
Deaf/Hard of Hearing
Deafblind
Orthopedic Impairment
Select One
Occupational Therapy
Physical therapy
Traumatic Brain Injury
Vision Impairment
Reason for discontinuation of Regional Services (select all that apply)
*
Graduated with diploma
Graduated with other certificate/diploma
Type of certificate
Reached maximum age (aged out)
No longer eligible
No longer eligible as of Date
Dropped Out
Dropped out as of Date
Moved to new location
Moved as of Date
Deceased
Deceased as of Date
Other
Reason
As of Date
Continue
Files
Required Documents:
Please include all relevant files. You can include multiple files in each input.
IEP/IFSP
*
Uploads:
Choose files to upload one at a time. Once a file is uploaded you can select another to upload.
Status Box
Signed Consent Form
*
Uploads:
Choose files to upload one at a time. Once a file is uploaded you can select another to upload.
Status Box
Eligibility Statement(s)
*
Uploads:
Choose files to upload one at a time. Once a file is uploaded you can select another to upload.
Status Box
Evaluation Report(s)
*
Uploads:
Choose files to upload one at a time. Once a file is uploaded you can select another to upload.
Status Box
Social Communication Assessment for Autism
*
Uploads:
Choose files to upload one at a time. Once a file is uploaded you can select another to upload.
Status Box
Medical Statement for Deaf/HH, Vision, Deafblind, OI, ID, & TBI Services
*
Uploads:
Choose files to upload one at a time. Once a file is uploaded you can select another to upload.
Status Box
Referral Checklist (STEPS Plus only)
*
Uploads:
Choose files to upload one at a time. Once a file is uploaded you can select another to upload.
Status Box
Other Files
Uploads:
Choose files to upload one at a time. Once a file is uploaded you can select another to upload.
Status Box
Continue
Review and Submit
Student: {{form.student_name_aka?form.student_name_aka:form.student_name_first}} {{form.student_name_last}}
School: {{form.attending_district}}, {{form.attending_school?form.attending_school:form.resident_school}}
Request Reason: {{request_type.prereferral?'Pre Referral Service, ':''}} {{request_type.evaluation?'Student Evaluation, ':''}} {{request_type.consultation?'Regional Consultation, ':''}} {{request_type.steps?'STEPS Program Services, ':''}} {{request_type.withdrawal?'Regional Services Withdrawn/Discontinued, ':''}}
Please list the name, title, and email of your district's approver. A copy of this request will be sent to them for approval before being submitted.
Approver Name
*
Approver Title
*
Approver Email
*
Submit
Please fill out all tabs to submit.
Southern Oregon ESD