District Referral Form
Complete this form to initiate referral. Form completion is not a guarantee of enrollment. ExcelPrep has a max limit on students who have aggression + daily living needs ranked as Severe-Profound.
Name of Referring School
Administrative Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Student's Date of Birth
*
-
Month
-
Day
Year
Date
Learner Diagnosis
Learner Age and Current (documented grade)
How soon are you looking to enroll this learner?
*
as soon as possible
within two months
Provide an overall summary including reason for referral
*
Learner Profile
Rows
Not a challenge at this time
Mild Challenge
Moderate
Severe
Profound
Receptive Language
Expressive Language
Reading Fluency and Comprehension
Social Communication
Maladaptive Behavior
Daily Living - Independence
Writing
Describe related services needed
Does the learner currently use AAC or any assistive technology
Yes
No
Does the learner present with any maladaptive behavior? If yes, please upload FBA data, BIP?
Yes
No
Upload IEP and other pertinent records
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