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

Autism Response Team:  Request for Consultation

Date of Request:

Student:                                                          District/School:

Birth Date:                                                      Grade:

Eligibities:

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?

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 Rodriquez at Bi-County (815) 622-3182**