SCHOOL LETTERHEAD
Date
Dear Doctor
Your patient ________________________________________ is having difficulty in school and has been
referred to the Education Support Team (EST). We have encouraged the student’s family to schedule an
appointment with you for further discussion and medical evaluation. The team is in the process of collecting
information that we hope you will find helpful in assessing this student.
The EST's concerns are:
As part of the pilot program being initiated in our community and supervisory union, we have obtained
permission from this student's family to have teachers complete the Teacher Report Form of the Achenbach
System of Empirically Based Assessment (ASEBA). The parents will complete the Child Behavior Checklist.
When complete and scored, you will receive a copy of that information.
The parents’ "Permission to Obtain or Release Records and Information" form is enclosed and is on file at school
as well. In addition to ASEBA information, the EST will send the information listed below.
If there is anything further that we can do to assist in regard to this student, please do not hesitate to contact us.
Sincerely yours,
Case manager
Encl:
 Permission to Obtain or Release Records and Information
 EST meeting notes
 Student Information Form K-6 or K-12
 Summary of past academic information
Cc to: Parents
 Health Office File
 EST File
 Special Education File
Primary Care Physician
 Other
Letter from school to primary care provider- Product of the VCHIP ADHD Practice Improvement Projects, 2008.