Referral for Direct Bilingual Assessment

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This form is to be used AFTER sending in a bilingual consultation form with your team, and being advised to put in a referral for direct assessment. Before filling this form out, please consult with your team to agree on assessments required from the Bilingual SLP or Bilingual Psychologist.

NOTE: From approximately 1/15/17 to 3/15/17, all assessment requests will be conducted with interpreters. After 3/15, bilingual academic, cognitive and adaptive assessments will resume with the Bilingual Psychologist, and after 4/15 bilingual speech-language assessments will resume with the Bilingual SLP.

Email *

Type of Referral

Initial

Re-evaluation

Screening

Clear selection

Do we have permission to test?

Yes

Clear selection

Is Spanish the primary home language? (must be YES to continue) *

Yes

Has the student previously been formally tested Spanish or bilingually? (if the answer is YES - consult with the bilingual team before proceeding) *

Yes (if "yes", only continue if directed to do so by bilingual team)

Is the student's Oral Language Composite on the ACCESS for ELLs test lower than 4.0, OR is the student a preschooler? (must be YES to continue) *

Yes

Time/Date of IEP

YYYY

Is the IEP date confirmed, or estimated?

Confirmed

Estimated

Clear selection

Student's Name

Grade

Date of Birth

YYYY

School

Classroom Teacher

School Hours

Specials (time)

ELD Block (time)

Lunch (time)

Psych

SLP

SSW

Nurse

Case Manager

Name of Person Referring and Title (psych or SLP)

Phone Number of Person Referring

Current Primary SpEd Label

Current Secondary SpEd Label

Medical Diagnoses (if applicable)

Current Placement (LRE or Program)

US Education

Kindergarten

1st

2nd

3rd

4th

5th

Additional years beyond 5th grade

Other:

Did the student pass the VISION SCREENING within the most recent 12 months? *

Yes

Did the student pass the HEARING SCREENING within the most recent 12 months? *

Yes

WIDA ACCESS level for Listening (1-6) *

WIDA ACCESS levels for Speaking (1-6) *

WIDA ACCESS levels for Oral Language (1-6) *

Bilingual Assessments Requested *

Speech-Language (Receptive and/or Expressive Language)

Academic

Cognitive

Adaptive Parent Interview

Other:

Required

Reason for Bilingual Evaluation Referral

Transfer not accepted

Potential change of disability/placement

Parent request

Not previously tested in Spanish

Other:

Additional Comments

A copy of your responses will be emailed to the address you provided.

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