To: New York City Department of Education
Committee on Special Education, District # ___
School Based Support Team, PS ______
Re: Name of Child
Child’s NYC ID# if available (if not, provide DOB)
To whom it may concern:
I am the parent of (Name of Child). I am writing to refer (Child’s first name) for
evaluation of eligibility for special education. (Child’s first name) is currently attending
the __ grade at PS ___. (If child is not in school, indicate, and delete School Based
Support Team as addressee above.)
IF APPROPRIATE: (Indicate if there is a specific concern. Eg, I am concerned that
(Child’s name) may be having difficulty with writing, so I am requesting that the
evaluation include an Occupational Therapy assessment. )
I understand that my consent is required in writing for my child to be evaluated to
determine whether s/he is eligible for special education, and again to begin providing any
recommended services.
My mailing address is __________________________ and my daytime telephone
number is ________________.
Thank you for your prompt attention to this referral.
Very truly yours,
________________
