School Age Student Services Inquiry

  • School Age Student Services Inquiry

    Not sure which service or program fits your student? Share a few details below and our Office of Student Services team will connect you with the appropriate contact.
  • Which best describes you?*

  •  

    Thank you for your interest in MCIU Student Services.

     

     
    Our programs are accessed through referrals made by school districts or educational teams. If you are a parent or caregiver, we encourage you to connect with your child’s school team to explore whether MCIU services may be an appropriate option.

     
    If you would like to learn more about available programs or have general questions, we are happy to help.

     
    You can:

    • Visit our website to explore services: www.mciu.org/oss
    • Contact our Office of Student Services at SAReferrals@mciu.org
    • Speak with your school district team about next steps


    We appreciate your advocacy and partnership in supporting your child.

     

     

  • Program Request Details

  • Desired School Year*

  • Program Selection

  • Classroom Program (choose all that apply)
  • Evaluation Services (choose all that apply)
  • Other Services (choose all that apply)

  • Student Information

  • Student Birthdate*
     - -
  • Gender*

  • Student Educational History

     

  • Is the Neighborhood School different than above?*
  • Is the Student considered a 1306 Student?*

  • Special Populations Designations

    A special Population Designation includes IEP, 504, EL or a Health Plan

  • Is there a special population designation with the student?*
  • IEP?*
  • 504?*
  • Health Plan?*
  • EL?*

  • Parent/Guardian Information

  • Format: (000) 000-0000.
  • Is the parent/guardian address the same as the student?*
  • Would you like to enter an additional address?*

  • School Contact Information

  • Format: (000) 000-0000.
  • Should the Authorizing Administrator be included on future communications for this referral?*

  • Additional School Contact Information

  • Is the person completing this form the same as the authorizing administrator?*
  • Format: (000) 000-0000.
  • Should the person completing this form be included on future communications for this referral?*
  • Is the person coordinating this referral the same as listed?*

  • Program Request Details

  • Document Uploads

  • Does the student have a Vocational Assessment?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Does the student have a Behavior Plan?*
  • Browse Files
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    Choose a file
    Cancelof
  • Does the student require a Personal Care Assistant?*
  • Does the student have any Medical Requirements?*
  • Upload a File
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    Choose a file
    Cancelof
  • Upload a File
    Drag and drop files here
    Choose a file
    Cancelof
  • Should be Empty: