Toolkit: Sample Written Request for an Evaluation to Determine Special Education Eligibility
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: ________________________________________________
Telephone Number: ___________________(home) ___________________ (work)
My child is receiving early intervention services from the following early intervention providers:
Early Intervention Program: ________________________________________
Contact Person: __________________________________________________
Service Coordinator: ______________________________________________
Special Child Health Services Address: _______________________________
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.
cc: Service Coordinator
Attachments (circle what is enclosed):
Individualized Family Service Plan
Health Examination Report