Special Education

Student Profile

New York State Approved Out-of-State Private Residential Program Placement Application2014-15 School Year - Word Word document (176 KB- includes instructions, application, assurance, referral chart and student profile)

A Name of Student
Last Name __________________First___________Middle_________

Date of Birth Month_____ /Day_____/Year

Gender ___ Male ____Female

Date of CSE Recommendation for Residential Placement

Month____ /Day____ /Year _____

With consent of parent, has the CSE made a referral to OPWDD and/or OMH? __ Yes  __ No __ N/A

Care and Custody of:
___ Parent
___ Legal Guardian
___ Department of Social Services
Specify County: ___________________

Last Name____________________________ First_______________________

Address Street_______________________________

City_______________ County___________________ State_____ Zip______

Home Telephone Number (      ) ___________
Work Telephone Number (      ) ____________

School District

District Contact - Last Name ____________________First________________

Email Address: ________________________

Title _______________________________________

Address - Street ______________________________

City ______________ County ________________ State________ Zip


Telephone Number (      )

___________________ Fax Number (      ) _____________________

B Request for Out-Of-State Placement:


Signature, CSE Chairperson                                                                  

C Name of Current Educational Program (not recommended placement):

(Please check the appropriate box below to indicate type of current educational program)

Emergency Interim Placement
Other State Agency Program

D CSE Classification:
(Please check one box to indicate the primary disability classification made by the CSE)



Multiple Disabilities*
Orthopedic Impairment
Other Health Impairment - Description: ______________________________

Traumatic Brain Injury

Traumatic Brain Injury

E Student Functioning Level:  Results of Latest Test of Intelligence
(Check the box that most closely indicates the results)

Intellectual ability

Adaptive Functioning

Language Functioning

Interpreter Needed:

Does this student require a sign language interpreter? ___ Yes ___ No
Does this student require instruction in Braille and the use of Braille? ___ Yes ___ No
Does this student require bilingual education? ___ Yes ___ No

Physical Functioning:




Medical Diagnosis: (Indicate any medical problems which may impact on the education of the child)

Psychiatric Disorder

Medical Needs:
Does this child have medical needs beyond the administration of medications which require daily individualized attention from health care staff? __ Yes __ No
Does this child require 24-hour nursing care?  __ Yes __ No
Please specify any medical alerts:   _____________________     

Behaviors Exhibited:

Behavior Frequency:

F Related Services Recommended:

School Health Services

Last Updated: March 31, 2014