Autism Screening Referral Form

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Please fill out this form to refer a student to the Autism Technical Assistance Team (ATAT) at Espanola Public Schools. an ATAT member will review the form and get in touch to acquire signed parent permission for screening if appropriate.

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* Indicates required question

Email *

Your email

Student Name:

Your answer

Student ID #:

Your answer

School/Grade/Teacher name:

Your answer

Your name:

Your answer

Your relationship to the student:

Your answer

Your contact info (phone/email):

Your answer

Provide a short description of your concerns:

Your answer

This student:

Has an IEP

Is in the SAT process

Is a regular education student

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