WESTMORELAND INTERMEDIATE UNIT
102 Equity Drive  Greensburg, PA 15601
NON-PUBLIC SCHOOL SERVICES - PSYCHOLOGICAL REFERRAL PACKET
Directions:
Referral for a psycho-educational assessment is the last step in a process of intervention and information gathering. The
purpose of these referral forms is to provide the psychologist with information that is needed before an evaluation can
begin. The psychologist wants to know:
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

Why the student is being referred for an evaluation?
What makes the student’s difficulties unique from his or her peers?
What previous steps school personnel have taken to resolve the problem?
The student’s behavior should be described in behavioral terms. Also, descriptions of daily classroom functioning should
be included. Please fill out the forms in detail and feel free to use extra pages as needed. Information provided in this
packet will help the psychologist to provide the best possible services. An incomplete referral packet will delay the
assessment/consultation process.
The following steps should be completed prior to returning the referral packet:
1) Send/Give the Permission to Evaluate form along with the Parent Input/Developmental History Form and its
Cover Letter to the parents(s). The parent(s) is to complete these forms and return to the school as quickly as
possible.
** Please have parents complete the Transition Survey ONLY if the student is 14 years of age or older.**
2) The School completes the Request for Psychological Evaluation Form along with the following: Teacher Input
Questionnaire, Acquisition/Retention Inventory, Classroom Observation Form, and School Nurse Input Form.
Additional copies of the Teacher Input Form may be given to more than one teacher if necessary. (Please answer
ALL questions and provide ALL information requested on all forms.)
**When completing the Classroom Observation Form, the observer should not be the teacher who is teaching at the
time of the observation.**
3) Please mail completed referral packet to:
Mr. Ronald Heitchue
Equitable Participation Specialist/School Psychologist
Westmoreland Intermediate Unit
102 Equity Drive
Greensburg, PA 15601
**A completed referral packet contains ALL of the following forms:
A.
B.
C.
D.
E.
F.
G.
H.
Signed Permission to Evaluate
Parent Input/Developmental History Form
Request for Psychological Evaluation Form
Teacher Input Form
Acquisition/Retention Inventory
Classroom Observation form
School Nurse Input Form
Transition Survey (only completed for students 14 years of age and older)
Parent Cover Level 1
WESTMORELAND INTERMEDIATE UNIT
102 Equity Drive  Greensburg, PA 15601
Date: __________________
Dear Parent or Guardian:
The attached Parent Input/Developmental History Form needs to be completed prior to conducting a
psycho-educational evaluation with your child. The information provided on this form will assist in
developing recommendations for your child. Please note that all information provided will remain
confidential and will only be used for the purpose of conducting the evaluation.
Should you have any questions regarding the completion of the Parent Input/Developmental History Form
you may contact me directly at the number listed below or you may contact your school for clarification.
Thank you in advance for your cooperation.
Sincerely,
Mr. Ronald Heitchue
Equitable Participation Specialist
Certified School Psychologist
724-836-2460 ext. 2391
Parent Cover Level 2