Bi- County Special Education Cooperative, Serving Whiteside and
Carroll Counties
506 W. 4th St., Suite B; Sterling, Illinois 61081; Phone
(815) 622-0858; Fax (815) 622-3182; www.bi-county.org
Date of Request: ________________
Student:
___________________________
District/School:
______________________
Contact Person: ____________________ Phone Number _______________________
Current
Special
Education Program and Related Services:
Names/Titles of Professionals involved with Student:
_____________________________________
_____________________________________
Is
student’s school team aware of/involved with this
request?
_____Yes _____No
Assistance
is needed for:
_________________________________________________________________________________
List communication, sensory processing, instructional intervention, and behavioral strategies attempted and/or in place:____________________________________________________________________________
_________________________________________________________________________________
What
has
been the level of success for these attempted
interventions?
_________________________________________________________________________________
_________________________________________________________________________________
Describe
the outcomes you would like from the consultation:
_________________________________________________________________________________
_________________________________________________________________________________
**Please
fax
to Linda Rodriguez at Bi-County (815) 622-3182**