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School Specialist Request Form
School Specialist Request Form
Member Name
*
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Medicaid ID Number
*
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Date of Birth
*
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County
*
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Bay
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Washington
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Name of School
*
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Grade in School
*
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Guardian Name
*
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Guardian Phone Number
*
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Guardian Email
*
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Preferred Language
*
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What type of help or support do you think your child needs at school? (Select all that apply)
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*
Behavior support
Mental health support
Academic support
Other
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What plans, if any, are already in place for your child at school? (Select all that apply)
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*
Individualized Education Plan (IEP)
504 Plan
Medical Plan
Behavior Intervention Plan
Safety Plan
None
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If you would like, please tell us what has been getting in the way of your child’s success at school.
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