Referral Checklist for Autism
Student’s Name ____________________________
Date sent to psych services* __________________
_____ Parent Input Form
_____ SST Meeting Summary & Intervention Plan
_____ SST Behavioral Supports Form (if applicable)
_____ Behavior Intervention Plan (if applicable)
_____ SST Follow-up Meeting Summary (if applicable)
_____ Permission to test with Prior Written Notice
_____ Student Support and Interventions Team Referral for Comprehensive Evaluation
_____ General Education Teacher’s Input Form
_____ Medical Information Form completed within the past year (A medical report by a licensed physician
evaluating the possibility of other impacting health conditions is required)
_____ Adaptive Behavior Evaluation Scale-Revised Second Edition School Version (ABES-R2 SV)
completed by classroom teacher
_____ Vineland-II Survey Interview Form completed in a direct interview with the parent OR for high
functioning students the Adaptive Behavior Evaluation Scale-Revised Second Edition Home
Version (ABES-R2 HV)
_____ Autism Spectrum Disorder Evaluation Scale – School Version (ASDES SV)
(Available upon request from the Educational Diagnostician)
_____ Gilliam Autism Rating Scale – Third Edition (GARS-3) completed by parent/guardian
(Available upon request from the Educational Diagnostician)
_____ Speech/Language/Communication Skills Evaluation (A Speech/Language Specialist is a required
member of the assessment team)
o A functional communication assessment
o Evaluation of phonology, morphology, syntax, semantics, and pragmatics
*(Please do not send the referral file to psych services until all information has been gathered and
included in the referral folder.)