Intellectual Disability Referral Packet
Student Information
Name
Date of Birth
Grade
Student ID
School
Parent/Guardian Information
Parent/Guardian Name
Phone
Email
Address
Reason for Referral
Describe the concerns leading to this referral
Educational History
Summarize previous evaluations, interventions, and outcomes
Medical History
Relevant medical information
Current Services/Supports
List current services or supports being provided
Additional Comments