(Physician’s Letterhead)
Date _____________
Dear ______________________School:
I am the physician taking care of your student, __________________________. He/she
sustained a concussion from a traumatic brain injury on ___________. The injury resulted
in the following disabilities which may adversely affect his/her educational performance:
o Visual impairment (including difficulty reading)
o Hearing impairment
o Cognitive impairment (including difficulty with concentration, memory, and retention)
o Speech/language impairment (including difficulty communicating)
o Fine or gross motor impairment (including difficulty with handwriting)
I am referring this student for an evaluation for Special Education and Related Services which
should include:
o A PPT meeting
o An IEP plan
o Consideration of the following related services:
 Psychological evaluation _______________________________________
 Counseling services ___________________________________________
 Guidance/Social work services __________________________________
 Audiologic services____________________________________________
 Speech and language services____________________________________
 Diagnostic PT/OT/Medical services
____________________________________________________________
____________________________________________________________
 Evaluation for assistive devices/technologies
____________________________________________________________
____________________________________________________________
 Academic accommodations or modifications as determined appropriate to
meet the needs of the student
____________________________________________________________
____________________________________________________________
____________________________________________________________
A signed Parental Consent form and the child’s medical records are enclosed. Thank you.
_____________________________________
(Physician’s Signature)
____________________________________
(Printed name)