HERKIMER BOCES
DEPARTMENT OF SPECIAL PROGRAMS
School Year: 2014 - 2015
REFERRAL BY C.S.E. for PLACEMENT
In order for the special programs Director and staff to make a proper placement, we must have TWO copies of this and the
documents noted on the reverse side. Please send these reports with this referral form. We must have the required reports
at least 5 days prior to student’s entry into program. We also require an on-site visit by the parents and potential student.
Please call the office to set up a visitation. Thank you for your cooperation!
- All Areas Must be Completed Student Name
Date of Birth
Parent/Guardian
Telephone
Address
COUNTY
School District of Residence
Date of CSE Action
CSE Chairperson Signature
Disability (ies)
Requested Class & Class Location
Teacher
Requested Date of Entry
ADDITIONAL REQUEST FOR SERVICE form MUST BE COMPLETED and INCLUDED
with this REFERRAL FOR PLACEMENT-if referral comes after start of school in September .
Free/Reduced Meal Form:
Not Applicable
Processed (copy attached)
 (Please send us a copy of current application if available.)
Medical Release/Approval:

Processed (copy attached)
Not Applicable
If student requires medication or special treatment items in school, this must be in place
with the school nurse before student begins attending!
Class Visitation: Date
Visitation by:
Student
(Please confirm in advance with office.)
Mother
Father
CSE Representative
Others (please specify)
Transportation Arrangements:
Bus #
Arrival Time
AM
_
PM
_
Departure Time
Special Arrangements:
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Please Also Complete Reverse (Pg.2)…
-- DATA / EVALUATIONS / OBSERVATIONS --
Please use only updated, current forms.
Submit TWO COPIES of all records (including this REFERRAL) to BOCES Special Programs Office.
NOTICE: The following documents and data must accompany this referral and be on file
before a student will be allowed to enter a BOCES program:

1. Parental Consent for Placement in a Special Education Program
2. 2014-2015 Consent for Release of Information to Access Medicaid Reimbursement Form
(This is mandated for district Medicaid Reimbursement.)
3. IEP for the 2014 - 2015 School Year
4. Current FBA (Functional Behavioral Assessment and BIP (Behavior Intervention Plan) for
students enrolled in Adjustment Programs OR for any student whose behavior interferes with
learning.
5. 2014-2015 BOCES Emergency Medical Data Form
(GUIDELINES kept by Parents-DO NOT SEND to BOCES WITH FILE)
6. BOCES Medication Release Form (to be completed regardless of whether or not student is to
receive medications during school hours. Must be completed by a physician to be valid.)
7. BOCES (Parent) Authorization for Use or Disclosure of Protected Health Form.
8. Current / Updated Social History - MUST BE DATED WITHIN LAST 3 YEARS
9. Health History - MUST BE DATED WITHIN LAST 12 MONTHS
(Please include all other pertinent medical records and PLEASE note any critical health conditions.)
10. Complete an up-to-date Immunization Record (No student will be accepted for special
education placement if immunization records are not complete.)
11. Psychological Evaluation - If not dated within last 3 years, then attach a narrative which
describes current levels of functioning and management needs.
12. Reports by other persons or agencies; i.e. evaluations in Speech/Language/Hearing;
Occupational Therapy; Physical Therapy; Psychiatric Evaluations; Social Services; etc.
13. Special Education Teacher / Specialists Observations and Recommendations (on criteria of
Academic, Social/Emotional, Physical Management Needs)
14. Doctor’s script for therapy services you may have on file if the student had been receiving
services prior to enrollment at BOCES – for this current school year.
15. ADDITIONAL REQUEST FOR SERVICE form if enrolling a new student after the beginning
of school in September 2014.
16. GUIDANCE transcript/report cards for students in 9th grade or older.
17. ALL Vocational Assessments completed.
18. Lunch Form (Proof of free or reduced. If not eligible, send a letter stating such for our files).
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law//sps students/enrollment packet/CSE Referral for Placement