APPENDIX B: WRITTEN REQUEST FOR AN EVALUATION TO DETERMINE ELIGIBILITY

Date __________________________
Dear Child Study Team:

The purpose of my letter is to request an evaluation to determine eligibility for special education services for my child.
Child's name: ________________________________________________
Birth-date: ________________________________________________
Parent's Name(s):______________________________________________
Address: ________________________________________________
________________________________________________
Telephone Number: ___________________(home) ___________________ (work)

My child is receiving early intervention services from the following early intervention providers. 
Early Intervention Program: ________________________________________
Address: ________________________________________________________
Telephone: ______________________________________________________
Contact Person: __________________________________________________
Service Coordinator: ______________________________________________
Special Child Health Services Address: _______________________________
Telephone: _____________________________________________________
My child will be turning three soon and I understand that we will need to meet to determine whether an evaluation is warranted. Please contact me to set up the time for this meeting. Please advise me of other residency documentation or pre-registration forms I may need to complete or furnish.

Thank you for your time. I look forward to hearing from you shortly and to working with you on behalf of my child.
Sincerely, 


(Parent)
cc: Service Coordinator
Attachments (circle what is enclosed): 

Individualized Family Service Plan	Evaluations
Provider's Observations	Health Examination Report