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Applicable only to students currently receiving special education programs or services.
*To be completed by the Local Educational Agency, Special Education Director or Designee.*

Select the program under consideration for this referral: (required) Progress Park Red Oak Young Adult LBC - Milan MS High Point Young Adult Project LBC - Dexter High School Young Adult Out-Centers LBC - Eberwhite

The WISD Referral Team may determine an alternate WISD program is appropriate for the student.

Date:

Student UIC Number:

SE Eligibility:

Date of Birth:

Home Phone Number:

Student Address:

District of Residence:

Parents/Legal Guardian:

Parent/Guardian Address:

Parent/Guardian Phone Number:

Alternate Phone Number:

Parent/Guardian Email:

Current Teacher/Case Manager:

**Parent Prior Written Notice Date:

WISD LRE TC:

Please explain the reasons for this Referral:

What motivates the student? Help for What motivates the student? Rewards, favorite activities, special relationships

The student is independent in: (required) Feeding Dressing Toileting

List other areas the student needs assistance with:

Is the student enrolled School of Choice? (required) Yes No

Does the student receive services under the McKinney-Vento Act? (required) Yes No

Sensory Needs and Strategies that work:

Does the student have a Behavioral Program/Plan? (required) Yes No

Interventions implemented for the following areas:

Social-Emotional

Implemented:

Date:

Unsuccessful Intervention:

Date:

Sensory

Implemented:

Date:

Unsuccessful Intervention:

Date:

Behavior

Implemented:

Date:

Unsuccessful Intervention:

Date:

Briefly describe how the student functions in the following areas:

Speech/Language (include language systems):

Cognitive Concerns:

Social/Community:

Fine Motor:

Gross Motor (equipment required):

What goals need to be achieved for this student's return to their home community?

Name of person completing this form:

Email Address:

District:

Role:

Phone Number:

Required Document Checklist:

Prior Written Notice (required) Available in PSSP Attached Not Applicable

IEP/IFSP (required) Available in PSSP Attached Not Applicable

REED/MET; in addition, SLP, OT, PT, O&M, and VI Reports (if applicable) (required) Available in PSSP Attached Not Applicable

Medical Records including plans and reports (required) Available in PSSP Attached Not Applicable

Mental Health/Psychiatric and Social Work reports (required) Available in PSSP Attached Not Applicable

PowerSchool Discipline Summary, Behavior Plans, Reports and Data including MDR(s) (required) Available in PSSP Attached Not Applicable

Teacher Reports (required) Available in PSSP Attached Not Applicable

Transcripts (required) Available in PSSP Attached Not Applicable

Statewide Assessment Reports (required) Available on PSSP Attached Not Applicable

Upload Required Documents:

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ADA & Accessibility

Our School Strives To Ensure Our Website Is Accessible To All Our Visitors

Washtenaw ISD is committed to providing a website that is fully accessible and we are currently in the process of developing a new website to better meet the needs of our customers. Our new website will include improvements to ADA compliance and accessibility, and during this transition, we remain committed to maintaining our existing website's accessibility and usability.

ADA Compliance

Non Discrimination

It is the policy and commitment of the Washtenaw Intermediate School District not to discriminate on the basis of race, color, religion, national origin, sex, disability, age, height, weight, familial status, marital status, genetic information, sexual orientation or any legally protected characteristic, in its educational programs, activities, admissions, or employment policies in accordance with Title IX of the 1972 Educational Amendments, executive order 11246 as amended, Section 504 of the Rehabilitation Act of 1973 and all other pertinent state and Federal regulations.

Non Discrimination Information

ADA and Title IX Coordinator	ADA and Title IX Coordinator
Brian Marcel Associate Superintendent 1819 S. Wagner Road Ann Arbor, MI 48103 (734) 994-8100 ext. 1402	Cassandra Harmon-Higgins Executive Director, HR & Legal Services 1819 S. Wagner Road Ann Arbor, MI 48103 (734) 994-8100 ext. 1311