Early Childhood Special Education Service Authorization Request Form
Please complete all sections to request authorization for early childhood special education services.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Service Requested
*
Please Select
Speech Therapy
Occupational Therapy
Physical Therapy
Special Instruction
Behavioral Support
Other
Requested Start Date of Service
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Requested End Date of Service
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Source of Authorization
*
Please Select
IEP Team Decision
Evaluation Report
Referral
Other
Brief Reason or Notes for Request
*
Submitted By (Name and Role)
*
Submit Request
Should be Empty: