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Special Education and 504 Referral Form

If a student is experiencing learning difficulties, his or her parent may contact the individual(s) listed below to learn about the school’s overall general education referral or screening system for support services. This system links students to a variety of support options, including making a referral for a special education evaluation or for a Section 504 evaluation to determine if the student needs specific aids, accommodations, or services.  A parent may request an evaluation for special education or Section 504 services at any time.  If you feel that your student may need services from either program, please submit this electronic form to the Student Services office, or contact:

*Contact Person for Special Education Referrals:

The designated person to contact regarding options for a student experiencing learning difficulties or regarding a referral for evaluation for special education services is:

Contact Person:  Lisa Robinson

Email:  ldrobinson@jeffersonisd.org

Phone Number:  903-665-2461, ext. 7

*Contact Person for Section 504 Referrals:

The designated person to contact regarding options for a student experiencing learning difficulties or regarding a referral for evaluation for Section 504 services is:

Contact Person:  Jessica Clark

Email:  jdclark@jeffersonisd.org

Phone Number:  903-665-2461, ext. 7

Please Fill Out The Special Education and 504 Referral Form Below

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(Please provide the following in order to contact you for completion of required referral paperwork.)


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Min: 1 Max: 5
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I would like my student tested for the following:


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Required Fields

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