Procedure – Category 5000 (Students) AR 5005.4 – SELPA Referral Procedures
The parent/guardian should initial each applicable statement listed under the Parental Authorization section of form DM 66. It is important that the parent/guardian return the form 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. 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, if known. If not, leave the field blank. B. Referral Procedures Forward the following completed documents to the attention of the OT/PT Supervisor at the SELPA. • DM 120A – Occupational Therapy Referral • DM 66 – Assessment Plan • DM 63 – Authorization for Use and/or Disclosure of Information • IEP or IEP Addendum dated within one year of the referral for occupational therapy. • Psycho-educational evaluation dated within three years of the referral for occupational therapy. • Any additional supporting information. C. Timeline for Assessment Within five business days of receipt of the completed referral packet, the OT/PT Supervisor at the SELPA will forward it to a SELPA occupational therapist. The assessment must occur within 60 calendar days from the date the Assessment Plan was received by the LEA. D. Timeline for Services
AR 5005.4 – SELPA Referral Procedures Desert Mountain Charter Special Education Local Plan Area (DMCS) (rev. 8/9/22)
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