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. I will follow up in a week, should you not have an opportunity to reach me sooner. 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’s Name)

cc: Service Coordinator

Attachments (circle what is enclosed): 
Individualized Family Service Plan 
Provider's Observations 
Evaluations
Health Examination Report