If the IEP team agrees that services are not needed, it will be documented in the IEP notes. If the IEP team agrees that services are appropriate, the services should be listed on an Addendum to the IEP including the projected start date, duration, and frequency. The Addendum should be forwarded to the Program Manager for Resolution Support Services at the SELPA. Within five business days of receipt of the Addendum to the IEP, the Program Manager for Resolution Support Services at the SELPA will develop an Individual Service Agreement (ISA) for signature and forward it to the occupational therapist or the appropriate Nonpublic Agency (NPA) for signature who will then assign a therapist and determine initiation of services. The SELPA will enter the OT services into the SELPA Management Information System (MIS) database. Transfer Referral
Pre-Referral Local Education Agency (LEA) Responsibility
1. Complete the Transfer into LEA form (D/M 52) and obtain the parent/guardian signature. 2. Complete the Authorization for Use and/or Disclosure of Information form (D/M 63) and obtain the parent/guardian signature. Specify the receiving agency’s name if known. If not, leave the field blank. 3. Complete the Occupational Therapy Referral form (D/M 120A) and obtain the signatures of the person making the referral and the director of special education. Referral Procedures Forward the following completed documents to the attention of the Program Manager for Resolution Support Services at the SELPA. • D/M 52 Transfer into LEA form • D/M 63 Authorization for Use and/or Disclosure of Information form • D/M 120A Occupational Therapy Referral form • Current occupational therapy report, if available, that specifies the occupational therapy services the student was receiving and the occupational therapy goals • IEP or IEP Addendum dated within one year of the transfer referral for occupational therapy that lists occupational therapy services and goals • Psycho-educational evaluation dated within three years of the transfer referral for occupational therapy
Chapter 22 – Supports and Services, Charter SELPA As of 10/17/2019 D/M Charter SELPA Steering Committee Approval
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