Early Childhood Special Education Referral Fax Back Form - Part 1 & Part 2 - Completion Instructions

Oct 10, 2026

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Early Childhood Special Education Referral Fax Back Form provides structured completion guidance for sending referral-related information between school district, health care providers, and referral sources based on parental/guardian consent. It specifies what to do upon initial contact or when contact cannot be established, including follow-up contact outcomes and dates. It also outlines post-eligibility completion steps, detailing eligibility determinations, recommended related services, IEP release procedures, and reasons if evaluation or assessment is not completed.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Part 1 of 2

Consent-based sending and initial/follow-up contact outcomes

Part 2 of 2

Eligibility results, recommended services, and IEP/summary release

Part 1 of 2 Part 1: To be completed upon contacting the family, or when a family cannot be contacted in a timely manner. 􀁸 If the parent/guardian consented to the release of information in Section 5 of the Standardized Request for Special Education Evaluation form to the health care provider listed in Section 3 and/or the referral source listed in Section 4, send Part 1 of the Referral Fax Back From to the health care provider and/or the referral source for which consent was provided. 􀁸 If the parent/guardian did not consent to the release of information to either the healthcare provider or the referral source, then information cannot be sent to the entity for which consent was not given. Today’s Date: Child’s Name: Date ofBirth: Parent/Guardian Name: Date Referral Received: This child was referred to School District. The following is the status of that referral: □ The family was contacted on (date): □ Repeated attempts have been made to contact this family – we were unable to establish contact. Please let us know if the family is still interested in having an evaluation for their child. Date final contact attempt made: □ The family requests that you contact them directly for results. Date request made by family: □ The family has declined services at this time. Date service declined: Additional Comments: Part 2 of 2 Part 2: To be completed after eligibility is determined and the Individualized Education Plan (IEP) is completed, if applicable, to inform the health care provider and/or referral source about Early Childhood Special Education eligibility and services recommended, if eligible. 􀁸 If the parent/guardian consented to the release of information in Section 5 of the Standardized Request for Special Education Evaluation form to the health care provider listed in Section 3 and/or the referral source listed in Section 4, send Part 1 of the Referral Fax Back From to the health care provider and/or the referral source for which consent was provided. 􀁸 If the parent/guardian did not consent to the release of information to either the healthcare provider or the referral source, then information cannot be sent to the entity for which consent was not given. Today’s Date: Child’s Name: Date ofBirth: Parent/Guardian Name: ______________________________________________________________________________ □ The family has been contacted and the following has occurred: □ The child has been evaluated and found to be not eligible for services at this time. □ The child has been evaluated and found to be eligible for services based on the following: □ Primary Eligibility: □ Secondary Eligibility: □ The child has been recommended to receive the following related services: □ Occupational Therapy □ Physical Therapy □ Speech Therapy □ Social Work □ Other: □ An IEP was developed for the child. The IEP Summary will be released to the health care provider identified in Section 5, Authorization to Release Information, in the Standardized Request for Special Education Evaluation form (a full copy of the plan may be obtained through the contact listed in Part 1) . □ The evaluation/assessment was not completed. Reason: Additional Comments:

FAQs

When should Part 1 of the Referral Fax Back Form be completed?

Part 1 is completed upon contacting the family, or when a family cannot be contacted in a timely manner.

How does consent affect what information can be sent?

If the parent/guardian consented to release information, Part 1 can be sent to the health care provider and/or referral source listed. Without consent, information cannot be sent to the entity for which consent was not given.

What is Part 2 used for after eligibility and the IEP are completed?

Part 2 is completed after eligibility is determined and the IEP is completed (if applicable) to inform the health care provider and/or referral source about Early Childhood Special Education eligibility and recommended services.

Oct 10, 2026

Uploaded by Fans