Referral Checklist for Emotional Disturbance Reevaluation
Student already has Emotional Disturbance eligibility
Student’s Name ____________________________
Date sent to psych services* __________________ (should be at least 4 to 6 months before the 3 year
reevaluation due date)
Date 3 year reevaluation is due: _______________
_____ Completed Reevaluation Summary Report
Assessment Plan in Section V of Reevaluation Summary Report includes:
Vision/Hearing (if not within the last 2 years); Sensory/Medical; Academic Achievement;
Intellectual Functioning; Social/Emotional Assessment; Social/Developmental History; Functional
Behavior Assessment; Other (Direct Observations)
_____ Parent Input Form
_____ FBA Report
_____ Behavior Intervention Plan
_____ Direct observation #1 by a licensed professional; cannot be completed by the same person that
provided the Classroom Teacher Observation in Section IV of the Reevaluation Summary Report
_____ Direct observation #2 by a third licensed professional in a different setting and at a different time
_____ Medical Information Form completed within the past year (to rule out physical conditions as the
primary cause of atypical behavior)
_____ Behavior Assessment System for Children, Second Edition (BASC-2) Teacher Rating
_____ Behavior Assessment System for Children, Second Edition (BASC-2) Parent Rating
_____ Behavior Evaluation Scale-Third Edition School Version (BES-3: L SV)
_____ Copy of the most recent psycho-educational evaluation report
*(Please do not send the referral file to psych services until all information listed above has been gathered
and included in the referral folder.)