HOUSTON INDEPENDENT SCHOOL DISTRICT
Office of Special Education Services

Hattie Mae White Educational Support Center
4400 West 18th Street

Houston, TX 77092

(713) 556-7025

 

REFERRAL FOR DISABILITY EVALUATION FORM

 

 

 

 

 

 

 

Student/Child Namel I Date I Raferral
Type
I th d? H_Student_Status_Report Attached
5 es en curren yenro . 
Major area of suspected disability(ies)
Academic Learning Behavior Communication Developmental Medical

 

 

Vision Screening Date Hearing Screening Date

 

 

Exclusionary Factors (The following have been ruled out in causing learning difficulties)

Do attendance patterns show that the student has changed schools so often, or has not attended school enough, that
normal achievement gains were not possible?

Have there been any significant or traumatic events in the student's life that contribute to the current learning problem 5?
Are there any factors in the student's school history that may be related to the current difficulty quality of teaching)?
Are there any variables related to family history that may have affected school performance?

Are there any variables related to the student's medical history that may have affected school performance?

Is the student's cultural background different from the culture of the school and larger society?



 

 

Describe the child's difficulty in accessing the grade level curriculum. (Describe the child's potential difficulty in accessing the grade level

curriculum, ifthe child is non-enrolled).

 

 

 

 

 

 

 

 

 

 

 

 

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Name, Administrator (Required) Name, Title

Last modified 8/11/14