Appendices AR 5005.4 – SELPA Referral Procedures
A. Terms and Acronyms Used in this Guide Terminology
Acronym
Assistive Technology
AT
Behavioral Health Counseling Desert Mountain Children’s Center Individual Service Agreement
BHC
DMCC
ISA LE LIE NPA NPS
Local Education Agency Low Incident Equipment Nonpublic Agency Nonpublic School Occupational Therapy Physical Therapy
OT PT
Residential Treatment Center Student Assistance Program School-Age Treatment Services
RTC SAP SATS SART SELPA
Screening Assessment Referral and Treatment Special Education Local Plan Area
B. SELPA Forms Referenced in this Guide Name of Form Authorization for Use and/or Disclosure of Information Transfer into LEA SBCSS/DMOPs Placement Services Referral Low Incidence Pre-Approval/Reimbursement Initial Request for Audiological Evaluation/Services Annual Request for Audiological Evaluation/Services Triennial Assessment Determination Occupational Therapy Referral Assistive Technology Assessment Referral Nonpublic School Placement Referral Special Health Care Services Referral Residential Placement Assessment Referral Assessment Plan IEP Forms Physical Therapy Referral
Form Number
DM 52 DM 63
DM 66
DM 68A – 68P
DM 85 DM 86A DM 108
DM 108A
DM 119 DM 120A DM 120B DM 127 DM 134 DM 148 DM 151
Referral for Behavioral Health Services SART Referral for Behavioral Health Services
DMCC 100A DMCC 100B
AR 5005.4 – SELPA Referral Procedures Desert Mountain Charter Special Education Local Plan Area (DMCS) (rev. 8/9/22)
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