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 as the SELPA. 3. Complete the Physical Therapy Referral form (D/M 120B) and obtain the signatures of the person making the referral and the director of special education. Referral Procedures Forward the following 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 120B Physical Therapy Referral form • Current physical therapy report, if available, that specifies the physical therapy services the student was receiving and the physical therapy goals • IEP or IEP Addendum dated within one year of the transfer referral for physical therapy that lists physical therapy services and goals • Psycho-educational evaluation dated within three years of the transfer referral for physical therapy Timeline for Assessment An assessment is not required for transfer referrals. Assessments are completed at three-year intervals (from the date that the services originally began) unless there are extenuating circumstances that dictate otherwise. Timeline for Services PT services for the student will begin immediately upon receipt of the physical therapy transfer referral packet by the SELPA physical therapist. The SELPA will enter the PT services into the SELPA Management Information System (MIS) database.
Chapter 22 – Supports and Services, Charter SELPA As of 10/17/2019 D/M Charter SELPA Steering Committee Approval
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