• What services are you interested in retaining for your student or adult? We provide both in school and in home support.

• Do you have a funding source established for this referral?

• If you are in Scioto County, is this referral to be billed through the SCOESC?

• Do you have parent or guardian consent to contact PS&C?

• Individual’s Name

• Individual’s DOB

• What are some of the individual’s interests? (e.g. hobbies, academics, etc.)

• What are some of the individual's strengths? (e.g. Social, academic, talents)

• Primary Teacher, Intervention Specialist Contact, or other service provider's contact's name, and title

• Primary Teacher's Email Address

• If there is a specific Room number or Home Room Number we will need this

• If the individual is receiving school services, what is the student's grade level?

• Parent or Caregiver Name and Address and Phone number, if an email is available we would like that too

• Name of School and Address (where services are provided) If services are to be provided at home then the home address

• Service Location's phone number

• Teacher, Intervention Specialist, or other school contact with whom we can schedule observations and discuss concerns

• What are the identified behaviors of concern?

• When and where are the behaviors most likely to occur? (e.g. specific classroom, time of day, school period etc.)

• When are they least likely to occur?

• If the individual has a diagnosis or diagnoses we will want to know

• Does the individual take medication? if so...what, when, and how much, for what?

• What is the individual's current schedule throughout the day?

• Does the student have an ETR and IEP?

• Please include the student's ETR, IEP, BIP, or ISP (if available). Feel free to attach other supporting documentation.

If you have all of the above information and would like to complete a form, please click below to complete and submit a referral form.