Procedure – Category 5000 (Students) AR 5005.4 – SELPA Referral Procedures
1. Convene an IEP meeting to document the team’s decision to refer the student for a PT assessment. 2. Complete the Physical Therapy Referral form (DM 120B) and obtain the signatures of the person making the referral and the director of special education. 3. Complete the Authorization for Use and/or Disclosure of Information form (DM 63) and obtain the parent/guardian signature. Specify the receiving agency as the SELPA. 4. Complete the Assessment Plan form (DM 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 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. B. Referral Procedures Forward the following documents to the attention of the OT/PT Supervisor at the SELPA. • DM 120B – Physical Therapy Referral • DM 63 – Authorization for Use and/or Disclosure of Information • DM 66 – Assessment Plan • IEP or IEP Addendum dated within one year of the referral for physical therapy. • Psycho-educational evaluation dated within three years of the referral for physical therapy. C. Timeline for Assessment
AR 5005.4 – SELPA Referral Procedures Desert Mountain Charter Special Education Local Plan Area (DMCS) (rev. 8/9/22)
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