ࡱ> >@=b _jbjb ,,mm@zzzzzzz 80<ld&,\RIiz"Izz(zzzzzzzz  440..zd  Date:  FORMTEXT       Student s Name:  FORMTEXT       DOB/Grade:  FORMTEXT      / FORMTEXT       Student s Primary Disability:  FORMTEXT       Parent:  FORMTEXT       Parent s Home Phone:  FORMTEXT       Work/Cell Phone:  FORMTEXT       District:  FORMTEXT       School:  FORMTEXT       Party Requesting ADR:  FORMCHECKBOX  Parent  FORMCHECKBOX  District Name and Role of District Contact :  FORMTEXT       Phone Number:  FORMTEXT       Email  FORMTEXT       Person Completing Form:  FORMTEXT       Area of Concern(s). Check all that apply:  FORMCHECKBOX  Eligibility  FORMCHECKBOX  Placement  FORMCHECKBOX  Services  FORMCHECKBOX  Timelines  FORMCHECKBOX  Assessment  FORMCHECKBOX  Failure to hold IEP  FORMCHECKBOX  Implementation of IEP  FORMCHECKBOX  Complaint Filed  FORMCHECKBOX  Other:  FORMTEXT       Briefly Explain:  FORMTEXT        FORMCHECKBOX  Copy of Most Current IEP faxed to ADR Case Carrier Date:  FORMTEXT        FORMCHECKBOX  Parent Referred to Matrix Parent Support Network: (415) 475-2119 ________________________________________ _____________________ Signature of Special Education Administrator/ Date Designee ************************************************************************ Please email this form to: adr_referrals@sonomaselpa.org, OR fax to the Sonoma County SELPA, Attn. ADR Staff at (707) 524-2754. The district contact person will be notified within 48 hours of receipt of this form. ***********************************************************************  ADR Staff Only ADR Intaker:  FORMTEXT       ADR Case Carrier:  FORMTEXT       Date Form Received:  FORMTEXT        FORMCHECKBOX  Special Education Administrator Contacted Date FORMTEXT           Sonoma County SELPA Referral For ADR Services SELPA 54 10/09 Copy 1: SELPA ADR File Copy 2: School Special Ed File Copy 3: Superintendent  "$&02TVjlnxz 468BDVXlnpvhjFh6h{NUjh{N5UmHnHujhh{N5Ujh{N5Uj^h6h{NUjh6h{NUjvh6h{NU jh6h{NUmHnHujh6h{NU h6h{Njh6h{NU h{N5(4F~(  l n | D B D R~`@&gd{N^^pz|  02FHJTVhj~   p r ؼخؠߖ߆ߖvjhh{N5Ujhh{N5Ujh{N5Ujh6h{NUjh6h{NUj.h6h{NUjh6h{NU h6h{N h{N5jh6h{NU jh6h{NUmHnHu+      D F Z \ ^ h j   " $ & @ B ^ ` ɻɭɟЕЅЕuЕej8hh{N5Ujhh{N5UjPhh{N5Ujh{N5Ujh6h{NUjdh6h{NUjh6h{NU h6h{N h{N5 jh6h{NUmHnHujh6h{NUjxh6h{NU'` b | ~    F H d f h      0 2 4 > q` jh6h{NUmHnHujd h6h{NU h6h{Njh6h{NUj hh{N5Uj| hh{N5Uj hh{N5Uj hh{N5Uj hh{N5Ujhh{N5U h{N5jh{N5U%> @ f h | ~ *,@BDNPRTprtfghwﯿ{rl]Sh6h{N5CJjh6h{N5CJU h{NCJh{N5>*CJ h{N5CJjh{N5UmHnHuj< hh{N5Uj h6h{NUjP hh{N5Ujh{N5U jh6h{NUmHnHuj h6h{NU h6h{N h{N5jh6h{NU HfhwZRTVX^bdhjnptvxz&$$d%d&d'dNOPQa$@&gd{N  24HJLVX*,@BDNPR^`df߻߻ō}߻kgbZgZjh{NU h{N5h{N"jh6h{N5CJUjh]h{NCJUjh{NCJU"jh6h{N5CJU"j(h6h{N5CJUh6h{N5CJ h{NCJ'jh6h{N5CJUmHnHujh6h{N5CJU"j h6h{N5CJU#fjlprzX^_ h{N5 h{N5CJ h{N5CJjh{NUh{N XYZ[\]^_gd{N$a$*:p{N/ =!"#$&%vDText22tDText2tDText3tDText4tDText5tDText6tDText7tDText8tDText9vDText10vDeCheck10vDeCheck11vDText11vDText12vDText13vDText14tDeCheck1tDeCheck5tDeCheck7tDeCheck2tDeCheck6tDeCheck8tDeCheck3tDeCheck9tDeCheck4vDText15vDText16vDeCheck12vDText17vDeCheck13vDText18vDText19vDText20vDeCheck14vDText21H@H Normal CJOJPJQJ_HmH sH tH DA@D Default Paragraph FontViV  Table Normal :V 44 la (k(No List 4@4 Header  !4 @4 Footer  !0U@0 Hyperlink>*B*H"H D Balloon TextCJOJQJ^JaJRY@2R {N Document Map-DM OJQJaJ,!zqH 67a"r)|}~Hfhw:;<=@LNb|}~0000`0`0`0`0`0`0`0`0`07`07`07`07`07`0`0`0`0`0`0`0`0`0`0`0`0`0`0`0`0`0h`0`0`0`0`0`0|B0RBR 0P 0P 0P ;0;=>0P 0P 0P 0AOqH 67a"r)|}~Hfhw:;<=000Հ000000000000000000000000000000000000000000000000000000000000000000000 >@p ` > f_ _ ^ *6<IU[]io $*4@F`py".4br #3O_s!')9&28FFFFFFFFFFG G FFFFG G G G G G G G G FFG FG FFFG F8@n( P L 6   B S  ?f]!t#Text22Text2Text3Text4Text5Text6Text7Text8Text9Text10Check10Check11Text11Text12Text13Text14Check1Check5Check7Check2Check6Check8Check3Check9Check4Text15Text16Check12Text17Check13Text18Text19Text20Check14Text21*I]4`y"b#Os)&  !"=\p +Gq 5s 4`(:9{@7J@::@BEHK|@| bd@@@ @ @@ @@@(@UnknownGTimes New Roman5Symbol3 Arial3Times5 TahomaC:f=`Lucida Grande phʆR ʆ  + !>4dV@:3qHP ?Date: _____________ Kelly Brooks Kelly Brooks Oh+'0 , L X d p|'Date: _____________Kelly BrooksADR Ref Form Template.dotKelly Brooks8Microsoft Word 11.5.5@hx@l5J5@8F5@T$QZ[  ՜.+,0 hp  'SCOE V Date: _____________ Title  !"#$%&'()*+,./012346789:;<?Root Entry FM[AData 1Table.WordDocument,,SummaryInformation(-DocumentSummaryInformation85CompObjX FMicrosoft Word DocumentNB6WWord.Document.8