Standard SESA Referral 

  • SESA Mutual Exchange of Information (MEI), Completed and signed by child’s guardian
  • District Referral Agreement, Signature of Special Education Director Required
  • Medical or school report documenting child’s diagnosis
  • Current, signed Individualized Education Plan (IEP)
  • Current, signed Evaluation Summary and Eligibility Report (ESER)
  • Contact information
This form is HIPAA/FERPA compliant. Information submitted through this form is encrypted. For more information about security and 123ContactForm, visit:

Frequently Asked Questions