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Preschool Special Education Referral Form
2023-2024 School Year
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* Indicates required question
Child's Name
*
Your answer
Child's DOB
*
MM
/
DD
/
YYYY
Child's Gender
*
Male
Female
Neighborhood School
*
Choose
Anna Smith Elementary
Copper Canyon Elementary
Dugway Schools
Grantsville Elementary
Middle Canyon Elementary
Northlake Elementary
Old Mill Elementary
Overlake Elementary
Rose Springs Elementary
Settlement Canyon Elementary
Stansbury Park Elementary
Sterling Elementary
Twenty Wells Elementary
Vernon Elementary
West Elementary
Willow Elementary
Parent/Guardian Phone
*
Your answer
Parent/Guardian Name
*
Your answer
Parent/Guardian Email
*
Your answer
Home Address
*
Your answer
Area(s) of Concern
*
Expressive Language (telling others what they want or how they feel)
Receptive Language (understanding simple directions)
Articulation (making correct sounds when saying words)
Cognitive (remembering information, understanding concepts)
Social/Behavioral (interacting with peers and adults, sharing toys, playing)
Self-Help Skills (performing age-appropriate, daily tasks on his/her own)
Fine Motor (development of the smaller muscles in the hands)
Gross Motor (development of large muscles in the arms, legs, and torso)
Other:
Required
What language is spoken in the home?
*
English
Spanish
Other:
First language spoken
*
English
Spanish
Other:
Does your child have a current IEP/IFSP?
*
Yes
No
Does your child have a medical condition?
*
If "yes," write in the "Other"
Yes
No
Other:
Required
Is this child or has this child received any type of private therapy (speech, ABA, etc.)?
*
Yes; Speech Therapy
Yes; Occupational Therapy
Yes; Physical Therapy
Yes; ABA Therapy
No
Other:
Required
Is your child enrolled in any early childhood programs?
*
Yes
No
Do you have any concerns about your child's vision?
*
Yes
No
Do you have any concerns about your child's hearing?
Yes
No
Clear selection
Is your child moving in from another school district?
*
Yes
No
Additional comments
Your answer
During the school year, please allow 5-10 business days for someone from the district to contact you. If you are filling this form out during summer hours, someone will contact you beginning of August.
TCSD Preschools: (435) 833-1966
Your answer
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