NOTE: Copy and paste the text below into a word processor and fill in the details about your child. When you fill in the blanks remove the dotted lines and the terms in brackets to create a “clean” copy of the letter.
My child, _______________________ [full legal name] is having difficulty in school. I suspect the difficulties are the result of an educational disability.
My child was born on __________ [date of birth]. He/She is in the ________ [grade] at ____________________ [name of school].
The reason for my referral is… [complete this sentence by using any of the terms on the list below which describe specific difficulties your child is experiencing in school].
low academic performance
poor attention span
behavioral difficulties
does not complete assignments
fine motor problems
gross motor problems
health concerns
visual concerns
hearing difficulties
attendance
speech problems
language problems
social interaction
any other
Some specific concerns are… [cite any specific examples of problems]
In order to prepare for the CSE meeting, I hereby give consent to the District to evaluate my child for educational disability, evaluations to include but not limited to: (1) a social history; (2) a psychological evaluation; (3) an educational evaluation; (4) a speech and language evaluation (if applicable); (5) an occupational evaluation (if applicable); (6) medical history; (7) any other relevant evaluations that might be useful in determining eligibility for classification as a disabled student.
Please note that I am aware of my rights. I have the right to a CSE meeting within 30 days of my request for a referral to the CSE. The meeting is to be held at a mutually agreeable time and location. Therefore, by law someone from your office is required to contact me directly well before the end of the 30 day time period to make arrangements to determine a mutually agreeable time and location so that the CSE meeting can be held within the 30 day period. I am not obligated to attend any pre-meetings or engage in any pre-CSE discussions. I will not sign any waiver forms of any kind. All I want is to hear back from your office in order to schedule the CSE meeting.
I also know that under New York State law, I am entitled to all documents that will be presented at the CSE in a reasonable period of time before the meeting. I want to have the opportunity to prepare for the meeting and seek advise of counsel prior to the CSE meeting based on the documents that will be used at the CSE meeting. Therefore I require that I receive copies of every document to be presented at the CSE meeting at least three (3) days prior to the CSE meeting. Any failure on the part of the District to schedule the meeting at a mutually agreeable time, to hold the meeting within 30 days, to work with me to schedule the meeting at a mutually agreeable time, to provide all documents in a reasonable amount of time prior to the meeting or any failure to properly convene and conduct the CSE meeting itself will result in my notifying VESID that the District failed to follow due process and is not in compliance with state and federal law and is therefore denying me my civil rights as well as those of my child.
As noted, I have a right to a meeting at a mutually agreeable time and location. I prefer the meeting be held at my child’s school.
I have included the following documents:
(1) reports cards/transcripts
(2) progress reports
(3) standardized testing
(4) primary pediatrician reports/medical records from specialists
(5) completed HIPPA release form authorizing the District to contact physicians directly to obtain information about my child
(6) proof of residence (2 utility bills showing my New Rochelle address) or proof of enrollment in a non-public school (a report card or a letter from the principal)
Thank you.
_________________________________________
Parent/Guardian signature