Parent Referral for Special Education
Prior to sending in this request, please connect with MacKenzie Bauer, School Psychologist, via email at mbauer@augusta.k12.wi.us or via phone at 715-286-2291 ext 4422
Student Name:
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First Name
Last Name
Student Grade:
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List the areas of concern for the student:
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Example: Academics, Cognitive Learning, Communication, Independence, Self-Determination, Social-Emotional Learning
State the reasons why you think the student has a disability:
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Summarize the student's current achievement with the following:
Student Strengths:
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Academic/Pre-Academic Achievement:
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Functional Performance in Relation to Peers:
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Example: Cognitive Learning, Communication, Independence, Self-Determination, Social-Emotional Learning
Relevant Medical Information:
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List Interventions/Programs the student has been involved in:
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Please include any behavior interventions as well
Parent/Guardian's Name:
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First Name
Last Name
Parent/Guardian Email:
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Submit
Should be Empty: