[Name]
[Address]
[City], CA [Zip Code]
[Telephone Number]

[Date]

[Director/Principal’s Name]
Director of Special Education [OR Principal of [School]]
[School District Name]
[Address]
[City], CA [Zip Code]

Re: [Student]

Dear Director/Principal [Name]:

I am the [parent/guardian] of [Student], who is [age] years old and currently enrolled in [Grade Level] at [School Name]. I write to refer [Student] for assessments to determine if she/he/they are eligible for special education services and support. [Student] is not progressing in school. 
I want the District to complete assessments including but not limited to a psychoeducational evaluation to evaluate my child’s cognition, psychological processing, and academic achievement. [If true, include: Additionally, I believe that my child may have [name suspected disabilities] and the school should complete additional assessments to evaluate these disabilities.  
I also request that the district evaluate my child under the provisions of Section 504 of the Rehabilitation Act of 1973 (Section 504) pursuant to title 34 C.F.R. Sec. 104.35, for the presence of any educational service need which may require any accommodation or program modification not available under special education or if my child is not found eligible for special education. I also request that the Section 504 Coordinator be present at the initial IEP meeting to discuss the results and recommendations of the Section 504 Evaluation. 
I look forward to receiving an assessment plan in 15 days pursuant to Education Code Sec. 56321(a). I hope that these evaluations can be completed promptly. Thereafter, we can have an IEP meeting to discuss the results of these evaluations and plan for [Student’s] continued education. Please ensure that I get copies of the assessment reports one week before the IEP meeting so that I may meaningfully participate in my child’s education.  Thank you.
Sincerely,

[Name]

CC: [Case Manager Name], [Student]’s Case Manager