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 Special Health Care Services Referral form (D/M 148) 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 148 Special Health Care Services Referral form • 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 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 Individual Service Agreement (ISA) and forward it to the appropriate Nonpublic Agency (NPA) for signature. Upon receipt of the signed ISA, the SELPA will forward the transfer referral packet to the appropriate NPA. The agency will contact the person who signed the referral to coordinate and begin services. The SELPA will enter the 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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