Special Education Intake

You have entered the online inquiry process for Clinton County RESA's Special Education.

This form is to refer individuals, 3 to 26, for possible special education services. When a referral is received, the parent or legal guardian will be contacted in order to discuss the referral and a possible evaluation for special education services. To place a referral for a child birth up to age 3, visit www.1800EarlyOn.org.

If you have questions about our online inquiry process, please feel free to contact us at . Service is also available for the deaf or hard of hearing by calling the Michigan Relay Center at 1-800-649-3777 for additional assistance.

Clinton County RESA serves students and families living in the following local school districts: Bath Community Schools, DeWitt Public Schools, Fowler Public Schools, Ovid-Elsie Area Schools, Pewamo-Westphalia Community Schools, and St. Johns Public Schools.

The referral can also be made by phone by calling our local referral line at: (989)224-5678

Referral Form
Required fields in Red
Do you need an interpreter?
¿Usted necesita a intérprete? Yes
No
How did you find out about us? Pediatrician
Hospital
Department of Health and Human Services
Teacher/Education Professional
Childcare Provider
Family Member
Web Site
Advertisement
Other
Child's Information
Child's Name:

If your child is close to turning age 3, they may be referred to the local special education program.
Date of Birth:
Grade Level:
School district where child currently resides:
Gender: Male
Female
Child's Ethnicity: American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Two or more races
Hispanic of any race.
Unknown
Was the child premature? Yes
No
Is the child a twin or triplet? Yes
No
The child has current or active IEP? (Individualized Education Plan): Yes
No
Unsure
The child has current or active IFSP? (Individualized Family Service Plan): Yes
No
Unsure
Are there speech and or language concerns? None
Speech: articulation/pronunciation
Language: the number of words
Both
Are you contacting us because you think your child was exposed to lead? Yes
No
Please give a detailed description of the child's concern/reason for referral:
Parent/Legal Guardian Information
Guardianship: Birth Parent
Adoptive Parent
Foster Parent
Legal Guardian
Other:

Parent Name:

Home Phone: () -
Alternate Phone: () - ext.

In order to send this referral on to the appropriate agency, we need an address. If the child and/or parent does not have a permanent address, please call 1-800-EarlyOn to make this referral.
We can not use P.O. Box numbers.
Address:

May we call the parent in the near future to ensure that they were connected with their local Early On? Yes
No
Your Contact Information
Your relation to the child: Parent
Grandparent
Sibling
Aunt or Uncle
Friend
Social Worker
Physician
Teacher
Childcare
Other:
Your Name:

Your Phone: () - ext.
Your Fax: () -
Your Address:

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