To submit this form, you can either email it to the designated special education coordinator or fax it to the number provided. If you prefer a physical submission, please mail it to the Macomb Intermediate School District's Special Education Office at the address listed on the form. It is crucial to ensure all necessary documentation is attached for the referral to be processed correctly.

For the upcoming school years, it is crucial to submit referral forms by the end of the first semester for timely evaluations. The deadlines for 2024 and 2025 will be communicated through the District’s official calendar.

The primary purpose of the Referral for Special Education Services Form is to initiate the evaluation process for students who may have learning difficulties or disabilities. By filling out this form, parents and educators ensure that students receive the necessary assessments, services, and support tailored to their needs. This process is vital in helping each child reach their maximum potential in an educational setting.

• 1. Student Last Name: Enter the last name of the student.
• 2. Legal First Name: Provide the student's legal first name.
• 3. Birthdate: Fill in the student's date of birth.
• 4. Age: Indicate the current age of the student.
• 5. Sex: Specify the student's gender.
• 6. Native Language: State the student's primary language spoken at home.
• 7. Student Address: List the physical address of the student.
• 8. City: Indicate the city of residence.
• 9. State: Specify the state.
• 10. Zip Code: Provide the relevant zip code.
• 11. Grade: Denote the current grade level of the student.
• 12. Legal Parent/Guardian Last Name: Enter the last name of the parent or guardian.
• 13. First Name: Provide their first name.
• 14. Relationship: State the relationship to the student.
• 15. Home Telephone: List a contact number for home.
• 16. Work Telephone: Include a work contact number.
• 17. Resident District: Specify the district where the student resides.
• 18. Attending District: Enter the district the student attends.
• 19. Attending Building: State the specific school building of attendance.
• 20. Current Educational Program: Explain the current program the student is enrolled in.
• 21. Current Teacher: Name the student's current teacher.
• 22. Reason for Referral: Provide a brief summary of the reason for referral.
• 23. Services Being Requested: List the specific services needed by the student.
• 24. Assessment: Mark applicable assessment services being requested.
• 25. Support Services: Indicate any additional support services needed.
• 26. Consideration for Program Placement: Check any conditions applicable for program placement.
• 27. Referred by: Enter the name of the person making the referral.
• 28. Title: Indicate the referer's job title.
• 29. Phone: Provide a contact phone number for the referer.
• 30. Signed: Signature of the legal parent/guardian or adult student.
• 31. Date: Enter the date of signing.
• 32. The required documentation is attached: A checkbox to confirm all needed documents are included.
• 33. Referring Director of Special Education: Name of the director overseeing the referral.
• 34. Distribution: Instructions for how and where to send copies of the form.

Failure to submit this form may result in delays in accessing special education services for the student. Proper referral ensures compliance with district policies.

• Delayed Evaluation: Without submission, evaluations needed to identify services cannot commence.
• Inaccessibility of Services: Students may miss out on critical support due to a lack of formal referral.
• Miscommunication: Failure to refer appropriately can lead to confusion regarding service availability.

• 1. Determining Eligibility: When assessing if a student meets the criteria for special education services.
• 2. Requesting Additional Services: When students require supplementary support not available in their current program.
• 3. Transition Planning: For students needing support as they transition between educational settings.