Cuyahoga DD School Supports Referral Form

Referral Form for Cuyahoga DD School Supports

(To be completed by school/district personnel)
Please contact SLP/AT Manager Janice Abram with any questions.

Phone: 216-780-4940

E-mail: abram.janice@cuyahogabdd.org
Thank you for your interest in Cuyahoga DD School Supports! Our role is to support board eligible students’ participation in their classrooms when interventions provided by the district have not been successful and/or when specialized supports needed are not provided by the school district. There may be a delay in response time if the student is not currently eligible for Cuyahoga DD. If you are unsure of eligibility status, please call 216-736-2673. Please complete the required information and click “submit” and a Cuyahoga DD staff will contact you. Thank you!
About the student being referred:
Student’s Name:*

First NameLast Name
Student’s Date of Birth:*

MonthDayYear
Date
Student's Home Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name: *

First NameLast Name
Parent/Guardian Phone Number:*

Area CodePhone Number
Parent/Guardian Email:*
Name of Student's School District:*
Name of Student's School:*
School Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of School Contact Person*

First NameLast Name
Title of School Contact Person:*
Phone Number for School Contact Person:*

Area CodePhone Number
Email for School Contact Person:*
Reason for referral:
Cuyahoga DD supports being referred to:

Professional development for district personnel provided by CCBDD staff related to AACOne-time in person Augmentative Alternative Communication (AAC) Consultation* (district personnel needing brief guidance for board eligible students regarding their services and supports that require a visit from Cuyahoga DD staff)AAC Equipment Lending Only* (Student has been assessed by the district SLP and in need of equipment only)
One-time in person Behavior and Curriculum Intervention Specialist (BCIS) Consultation* (defined as district personnel needing brief guidance for board eligible students regarding their services and supports that require a visit from Cuyahoga DD staff)
Please describe the following in the section below:*
Describe the interventions tried thus far leading up to this referral. List any equipment that has been trialed leading up to this referral and how that has worked. If the referral is for AAC, describe how the individual is currently communicating in the classroom.
Statement of Concern:*
About the person making this referral:
Referred by:*

First NameLast Name
Title:*
Phone:*

Area CodePhone Number
Email Address:*
Our new referral process requires that a Supervisor or their designee complete or approve the referral.
Name of person approving the referral:
Name:blanks*
Title:blank*
Parent/Guardian Permission

Parent/Guardian permission for this referral must be obtained prior to submitting this form. You must complete the following:
Date permission obtained*

MonthDayYear
Date
By (Name of parent/guardian)*

First NameLast Name
Method permission obtained:*

In personBy phoneBy email
Upload Attachment*

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I have attached a release of information signed by the parent/guardian to this electronic referral.
I have attached the current IEP
I have attached the current ETR
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Referral Form for Cuyahoga DD School Supports

About the student being referred:

Reason for referral:

About the person making this referral:

Parent/Guardian Permission