Procedure – Category 5000 (Students) AR 5005.4 – SELPA Referral Procedures
3. Complete the Authorization for Use and/or Disclosure of Information form (DM 63) upon receipt of the Assessment Plan form (DM 66) and obtain the parent/guardian signature. Specify the agency’s name, if known. If not, leave the field blank. The parent/guardian should initial each applicable statement listed under the Parental Authorization section of form DM 66. It is important to remind the parent/guardian to return forms DM 66 and DM 63 to the LEA on the date that it is signed or as soon as possible thereafter. When the signed Assessment Plan is received by the LEA, it should be date stamped or return date written at the bottom of form DM 66. 4. Identify the NPA assessor to complete the assessment within the 60-day timeline. B. Referral Procedures Forward the following completed and signed documents to the attention of the Program Manager for Resolution Support Services: • Cover letter requesting an FBA. NOTE: The director and the NPA determine the maximum number of hours needed to conduct assessment. Please indicate which NPA the LEA is selecting to complete the FBA. • DM 66 – Assessment Plan • DM 63 – Authorization for Use and/or Disclosure of Information • IEP or IEP Addendum dated within one year referring the student for a behavioral intervention assessment. • Psycho-educational evaluation dated within three years of the referral for a behavioral intervention assessment. • Other assessments (i.e., private evaluations, Occupational Therapy (OT), Physical Therapy (PT), etc.) • Behavior plans (original and revised versions)
AR 5005.4 – SELPA Referral Procedures Desert Mountain Charter Special Education Local Plan Area (DMCS) (rev. 8/9/22)
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