Create Your Own Referral Letter

This form letter is for use by parents to refer their children for initial evaluations under the IDEA.

Parent's Name*
First Last
Parent's Mailing Address*
Street Address Address Line 2 City State ZIP Code
Parent's Phone*
Parent's Email*
Name of Local Education Agency*
LEA Contact Person*
The name or title of the person at your local education agency to whom you are addressing this request; this is often a Special Education Program Coordinator, Director of Special Education, Assistant Superintendent of Educational Services, etc. If you are not sure, just leave it at the default "Special Education Director."
Local Education Agency Address*
Street Address Address Line 2 City State ZIP Code
Name of Student*
Student's Date of Birth*
Student's Current Grade Level*
Student's Current School of Attendance*
Parent Concerns*
Describe the things you are seeing that give you cause to suspect that your child may have a disability that is interfering with your child's learning, access to instruction, and/or ability to participate in school with other students appropriately.