How to fill out the E1 Form When

When should the form be filled out? ❏ Steps 1 -2 should be filled

Step 1 ➢ Make sure to completely fill out this section. ➢ Individual (s)

Step 1 continued ➢ Date Request Received: ➢ Parent Referral: The date of the

Step 1 Continued ➢ Make sure to mark all areas that are appropriate and

Step 2 ➢ Describe the factors that were used to make the decision regarding

Step 3 This matches the referral date on step 1. If the request is

Step 3 ➢ Agency Referral: This will be the names and roles of the

Where to access the E-1 Form? � The E-1 form is located on the

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How to fill out the E-1 Form

When should the form be filled out? ❏ Steps 1 -2 should be filled out upon referral (prior to the RED meeting) ❏ Step 3 ◦ Agency Referral: Should be filled out by the counselor prior to the RED Meeting. This would be filled out when the team determines to send it to RED. ◦ Parent Referral: Should be filled by the out at the admin meeting ❏ Please make sure to fill this form out completely.

Step 1 ➢ Make sure to completely fill out this section. ➢ Individual (s) Making Request: This should be the person or person’s name and role. It is not acceptable to put CARE or Problem Solving Team. In most cases this will be the Problem Solving Team, Student Study team, etc.

Step 1 continued ➢ Date Request Received: ➢ Parent Referral: The date of the referral is the date a member of the agency’s certificated staff receives a request from the parent (either verbal or written) ➢ Agency Referral: The date on which the agency made the referral. ➢ Name of Agency Staff who received request: Enter the first and last name of the person or persons who received the request this must be a certificated staff member. ➢ Form in which request received: You must mark one box, either written or verbal.

Step 1 Continued ➢ Make sure to mark all areas that are appropriate and describe the specific concerns for the student in each one of the areas selected.

Step 2 ➢ Describe the factors that were used to make the decision regarding the suspicion of a disability. ➢ Mark the appropriate box if a disability is not suspected or if a disability may exist and is suspected.

Step 3 This matches the referral date on step 1. If the request is made by a parent this column should be filled out completely. If the request is made by District personnel this column should be filled out completely.

Step 3 ➢ Agency Referral: This will be the names and roles of the team members who determined that an evaluation is warranted. (In most cases the would be the student study team, Problem Solving team, etc) ➢ Parent Referral: This will be the names and roles administrative review team that is making the determination. ➢ Make sure to list first and last names and team member roles.

Where to access the E-1 Form? � The E-1 form is located on the Special Education Resource Moodle site. � Once you log into the Moodle site it is listed under: ◦ Forms for Counselors