Procedure – Category 5000 (Students) AR 5005.4 – SELPA Referral Procedures
12.2 Transfer Referral ...................................................................................................... 34 13.0 S PECIAL H EALTH C ARE S ERVICES ................................................................................. 35 13.1 Initial Referral .......................................................................................................... 35 13.2 Transfer Referral ...................................................................................................... 37 14.0 D ESERT /M OUNTAIN O PERATIONS (DMOP S ) ................................................................. 38
1.0
Audiological Assessment
1.1
Initial Referral The SELPA Audiological Program provides students with audiological assessment and services that will assist the students to participate and progress in the general education curriculum. A. Pre-referral Local Education Agency (LEA) Responsibility: 1. Convene an Individualized Education Program (IEP) meeting to document the team’s decision to refer the student for an audiological assessment. 2. Complete the Initial Request for Audiological Evaluation/Services form (DM 108) and obtain the signatures of the person making the referral and the director of special education. 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 DM 66. 3. Complete the Assessment Plan form (DM 6) and obtain the parent/guardian signature. 4. Complete the Authorization for Use and/or Disclosure of Information form (DM 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.
AR 5005.4 – SELPA Referral Procedures Desert Mountain Charter Special Education Local Plan Area (DMCS) (rev. 8/9/22)
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