Procedure – Category 5000 (Students) AR 5005.4 – SELPA Referral Procedures
13.2 Transfer Referral A. Pre-referral
LEA Responsibility: 1. Complete the Transfer into LEA form (DM 52) and obtain the parent/guardian signature. 2. 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. 3. Complete the Special Health Care Services Referral form (DM 148) and obtain the signatures of the person making the referral and the director of special education. B. Referral Procedures Forward the following documents to the attention of the Program Manager for Resolution Support Services at the SELPA. • DM 52 – Transfer into LEA • DM 63 – Authorization for Use and/or Disclosure of Information • DM 148 – Special Health Care Services Referral • Current Summary of Treatment Plan, if available, that specifies the special health care services the student was receiving. • IEP or IEP Addendum dated within one year of the referral for special health care services that lists the special health care services the student was receiving. • Psycho-educational evaluation dated within three years of the referral for special health care services. C. Timeline for Services Within five business days of receipt of the completed referral packet, the Program Manager for Resolution Support Services at the SELPA will develop an ISA and forward it to the appropriate NPA for signature.
AR 5005.4 – SELPA Referral Procedures Desert Mountain Charter Special Education Local Plan Area (DMCS) (rev. 8/9/22)
Page 37
Made with FlippingBook - professional solution for displaying marketing and sales documents online