Audiological Assessment - Initial Referral

Audiological Assessment | Initial Referral

The SELPA Audiological Program provides students with audiological assessment and services that will assist them in making the best use of their hearing and help them participate and progress in the general curriculum.



  • Convene an Individualized Education Program (IEP) meeting to document the team's decision to refer the student for an Audiological Assessment.
  • Complete the Initial Request for Audiological Evaluation/Services form (D/M 108) and obtain the signatures of the person making the referral and the director of special education.
  • Complete the Assessment Plan form (D/M 66) and obtain the parent/guardian signature.
  • The person making the referral should check the box that corresponds to the type of assessment(s) requested.
  • The parent/guardian should initial each applicable statement listed under the Parental Authorization section of form D/M 66.
  • LEAs are encouraged to have assessment plans signed close to the date of their LEA audiology evaluation date and within the required time frame.
  • Complete the Authorization for Use and/or Disclosure of Information form (D/M 63) and obtain the parent/guardian signature. Specify the receiving agency's name as the SELPA/Pacific Hearing Services. The disclosing agency will vary depending on whether it is a physician, medical center, or audiologist.


Timeline for Assessment

The audiological assessment must occur within 60 calendar days from the date the Assessment Plan was received by the LEA. When the signed Assessment Plan is received by the LEA, it should be date stamped.

An Audiology Assessment Calendar is published on an annual basis at the beginning of each school year. The calendar lists the assessment dates and referral due dates for each LEA within the SELPA. The calendar can be found on the SELPA website at

For students who require services outside of the regularly scheduled LEA visit, services may be coordinated between the SELPA and the LEA. Arrangements may be made for students to be served at the school site, at a nearby LEA, the Desert/Mountain Children's Center (DMCC), or at the service provider's office, whichever is available and appropriate. Please contact the Audiology Services Program Specialist at the SELPA for assistance.


  • D/M 108 Initial Request for Audiological Evaluations / Services form
  • D/M 66 Assessment Plan form
  • D/M 63 Authorization for Use and/or Disclosure of Information form
  • IEP or IE Addendum dated within one year of the referral for an audiological assessment
  • LEA's hearing screening form that documents a minimum of two repeated failures on threshold tests or previous audiological assessment reports and/or audiograms for students who have an identified hearing loss


Timeline for Services

Upon completion of the audiological assessment, a report will be sent to the director of special education by either the agency that conducted the assessment or by the Audiology Services Program Specialist at the SELPA.

The director of special education should reconvene the IEP team to review the findings and recommendations of the assessment, consider the educational impact, and determine whether or not audiological services are needed.

For more information, please contact our office at (760) 552-6700