Initial Referral
Committee on Preschoo
l Special Education
ESSEX COUNTY
Child:__________________________________________________ School District:____________________ Foster Child: Y / N
First, Middle Name Last circle
DOB:_____________ Age:_______ Sex:________ Native Language:___________ Racial/Ethnic Category:________
Parent /Guardian:__________________________________ Parent / Guardian:______________________________________
Relationship to child:__________________________ Relationship to Child:___________________________
Address:_________________________________________ Address:_________________________________________________
_________________________________________ _________________________________________________
Phone: (Home):____________________________ Phone: (Home):________________________
Phone: (Work):____________________________ Phone: (Work):_________________________
Emergency Contact Information
Name:________________________________ Phone:___________________ Relationship to Child:_________________
Person Making Referral Information
Name:________________________________ Phone:___________________ Relationship to Child:__________________
Address:________________________________City:_________________________ NY Zip:_____________
Physician Information
Name: ___________________________________________ Phone:____________________
Address:_______________________________________City:__________________________NY Zip:______________
Significant health issues/medical alerts:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Current Program/Services:_________________________________________ Site:______________________________________
_______ SEIT Provider:____________________________ Frequency/Duration______________________________
_______ OT Provider:____________________________ Frequency/Duration______________________________
_______ PT Provider:____________________________ Frequency/Duration______________________________
_______Speech Provider:____________________________ Frequency/Duration______________________________
_______other Provider:____________________________ Frequency/Duration______________________________
Reason for referral (describe in detail):
************************************************************************************************************
MANDATED COMPONENTS
ADDITIONAL ASSESSMENTS
______ Psychological _______ PT
______ Social/history
_______ OT
______ Physical _______ Speech
_____ Observation of child _______ Audiological
_______ Functional Behavioral Assessment
_______ Other:_____________________
CPSE Chairperson’s Signature:_______________________________________________ Date Received:____________
Referral Date:
Do not alter Essex County Forms. They have been designed to meet State and Federal requirements.
and/or natural environment
