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Calaveras County SELPA - Referral for SELPA Support - Intake Form
Alternative Dispute Resolution Services
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* Indicates required question
Email
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Your email
Today's Date/Fecha:
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MM
/
DD
/
YYYY
Your name/Su Nombre:
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Your answer
Student Name/El Nombre de Estudiante:
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Your answer
Student Birthdate/Fecha de Nacimiento del Estudiante:
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MM
/
DD
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YYYY
Relationship to student/Relación con la estudiante:
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Parent/Guardian/El Padre/Guardián
School District/Distrito Escolar
What is the best phone number to reach you?/¿Cuál es la mejor dirección de correo electrónico para contactarlo?
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Your answer
What is the best email address to reach you?/¿Cuál es la mejor dirección de correo electrónico para contactarlo?
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Your answer
What is the district for this student?/ Cual es el districto escolar de su estudiante?
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Choose
Calaveras Unified School District
Bret Harte Union High School District
Mark Twain Union Elementary School District
Mountain Oaks School
Vallecito Union School District
Calaveras County Office of Education
What school does your child attend?/¿A qué escuela asiste su hijo?
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Your answer
Is your child on an IEP or a 504 Plan?
Yes
No
Clear selection
What concerns do you have that prompted a request for ADR support through the Calaveras County SELPA?/¿Qué inquietudes tiene que provocaron una solicitud de apoyo de ADR a través del SELPA del condado de calaveras?
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Lack of educational progress/Falta de progreso educativo
Placement/Colocación
Services/Services
Poor communication/Mala comunicación
Other:
Required
Is this the first request for ADR services through Calaveras County SELPA for this student?/¿Es esta la primera solicitud de servicios ADR a través de SELPA del condado de Calaveras para este estudiante?
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Yes/Sí
No/No
What steps have taken place to come to an agreement as a team?/¿Qué pasos se han dado para llegar a un acuerdo como equipo?
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IEP Meeting/Reunión del IEP
Meeting with school administrator/Reunión con el administrador de la escuela
Meeting with district level administrator or support person/Reunión con el administrador a nivel de distrito o persona de apoyo
Other:
Please share your concerns in more detail:/Comparta sus inquietudes con más detalle:
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Your answer
What would be your desired outcome?/¿Cuál sería su resultado deseado?
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Your answer
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