LEEP Referral Form

In order to process your referral in the most efficient manner, please be certain that required documents are attached. Please refer to the LEEP Overview and Referral guide:

https://docs.google.com/document/d/1Ec-UX7bElh04VbtcUsRWXMbMdEcdzqQlUXKC1WxDvoA/edit?usp=sharing

Please complete this form to begin the referral process.

TO BE COMPLETED BY SCHOOL DISTRICT STAFF ONLY

Today's Date*

Reason for Referral *

Select or enter value

Student Information

First Name (Legal Name)*

Last Name (Legal Name)*

Grade*

Select

DOB

Gender

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Resident District*

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School Attending*

Are Languages Other Than English Spoken at Home?

Select or enter value

If Yes, Primary Language?

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Parent/Guardian Name(s)

Guardian Address (incl: city, state, zip)

Guardian Email Address(es)

Guardian Primary Phone #/Type

Guardian Alternative Phone #/Type

District Rep/Contact*

District Contact Email*

District Rep Contact Phone #/Type

Notes

File Attachments*

Please review the link below for applicable documents required:

https://docs.google.com/document/d/1Ec-UX7bElh04VbtcUsRWXMbMdEcdzqQlUXKC1WxDvoA/edit

Required Documents (as applicable):

IEP - Current Oregon IEP
Current Oregon Eligibility Documents
Current Placement
Functional communication assessment
Functional Behavior Assessment
Abbreviated school day documentation
Nursing assessments
Feeding protocol
All Medical protocol(s)
All Student plan(s)

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