100 East Third Street, P.O. Box 578 Piketon, Ohio 45661 Phone: 740-289-4171
475 Western Avenue Chillicothe, Ohio 45601   Phone: 740-702-3120
View Ross Pike ESD & SST 15

District Autism Team Observation Request

Ross Pike ESC Autism Team Observation Request
Please use this form when you would like a child in your district to be evaluated for an educational determination of Autism. This form does not supersede the processes and procedures of the MFE process, however, it insures that you will have a trained team assist you with the process.

Please indicate the name of the District Representative making this request.
Please indicate the District making the request.

Name of Student
Student Grade:
Date of the planning meeting that you would like someone to attend.
Brief description of what led you to believe that the Autism Team is necessary for your student.
Phone Number where you can be reached for questions
Email where you can be reached
Your Name:
Your Email:

To validate your submission, please answer the following math problem:

captcha math problem
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