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STUDENT INFORMATION:

Home School District*

Last Name*

First Name*

DOB*

Dominant Language

Other Language

District Contact Person

District Contact Email*

Current Placement & Grade Level

FAMILY INFORMATION:

Parent/Guardian*

Home Phone Number

Mother Work Number

Father Work Number

Street Address*

City*

State*

Zip Code*

Emergency Contact

Emergency Phone Number

Requested Start Date*

COMMITTEE ON SPECIAL EDUCATION INFORMATION:

Last Psych Eval Date *

IEP Date*

Classification*

School Year *

Recommended Placement*

8:1+1	8:1+2	9:1+3
6:1+2	6:1+3	6:1+3.5
6:1+1

RECOMMENDED PROGRAM:

Goshen Center Programs

Liberty Elementary Program (Gr. K-5)

Raymond C. Cramer (Ages 5-21)

STRIVE (Ages 5-21)

John A. Flannery Middle/High School (Gr. 6-12)

GED Program

Arden Hill Programs

Academy at Arden Hill Middle.High School (Gr. 6-12)

Marguerite A. Flood Middle/High School (Gr. 6-12)

Marlboro Program

Middlehope Elementary (Gr. K-5)

Referral Date

Satellite Programs

Goshen Including Communities (Ages 19-21)

Goshen Main Street (Ages 14-21)

Minisink Middle/High (Ages 11-21)

Minisink Otisville Elementary (Ages 5-8)

Pine Island Elementary (Ages 5-11)

RELATED SERVICES GROUP/INDIVIDUAL SESSION/WEEK

Speech/Language Therapy

Counseling

Physical Therapy

Occupational Therapy

Visually Impaired Services

Hearing Impaired Services

Nursing Services - Specify

Sign Language Interpreter

Specify

1:1 Aide

Please indicate the level of ENL Services:

Expected School Credential:

Test Modifications or Exemptions?

Behavior Intervention Plan?

Is the primary language spoken at home English?

Yes

No

New York State Alternate Assessment (NYSAA) Eligible?

Yes

No

Special Busing?

Special Equipment?

Medication?

Is this student Medicaid eligible?

Yes

No

Unknown

CIN Number:

Reason for Referral:

The Committee on Special Education has determined that this student can no longer benefit from programs available in the home district and, having considered all less restrictive placements, is recommending placement in a BOCES program as described above for the following reason(s):

This student’s behavioral controls have diminished such that he/she requires a highly structured program in a special education facility. (Please provide existing Behavior Intervention Plan)

This student is unable to establish and maintain satisfactory relationships with peers and/or adults.

This student requires intensive and highly individualized class placement, academic program and/or related services in a special education facility.

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NYS Science Investigations

For state tested students in grades 3-8, check off the investigations that the student has completed AND provide the necessary supporting documentation for each investigation.

Elementary Level Investigations (Grades 3-5)*

What's in the bag?

Cloud in a bottle

Light it up!

Circle of life

"Other: The student has not completed any of the Elementary Investigations and/or is not required to complete the Elementary Investigations"

Intermediate Level Investigations (Grades 6-8)*

All mixed up

Cool it!

How's the weather up there?

It's alive?

"Other: The student has not completed any of the Intermediate Investigations and/or is not required to complete the Intermediate Investigations"

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Please note: Be sure to attach all current evaluations, reports, prescriptions, etc. for any Related Services. An Intake Conference will not be scheduled or a placement decision made without complete referral material on files.

The following records should be included with this Referral Form:

*Current IEP

* Recent Social History

*Recent Psychological Evaluation

*Health and Immunization Records

*Other Educational, Diagnostic or Anecdotal Records

* Academic Achievement Data

*Transcripts (as appropriate)

*Disciplinary Records

* Related Service Evaluations, Prescriptions, etc.

*Behavior Intervention Plan

*Documentation pertaining to the NYS Science Investigations

Attach Required Documents

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or drag a file here

Attach File

Attach Additional Documents

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Attach File

Signature

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Authorization*

By checking this box and signing you are authorizing that you are the district contact person submitting this form

Please Type Full Name

Date