Referral Procedures Forward the completed Referral for Behavioral Health Services form (DMCC 100A) to the attention of the Director of the DMCC. Timeline for Assessment Upon receipt of the completed Referral for Behavioral Health Services form (DMCC 100A), the DMCC will contact the parent/guardian by letter (up to three times) to schedule the assessment intake meeting. An intervention specialist or behavioral health counselor will be assigned to conduct the assessment. If no response from the parent/guardian is received by the third letter, the referral will be closed.
Timeline for Services If services are not deemed appropriate, the referral will be closed.
If services are deemed appropriate, a clinician will be assigned and services will begin. The DMCC provides a monthly report to the directors of special education. The report includes a list of students who are currently served by the DMCC as well as an update for each referral that is in process. Section 4: Nonpublic Agency Behavioral Intervention Behavioral Intervention Assessment Only Pre-Referral Local Education Agency (LEA) Responsibility 1. Convene an Individualized Education Program (IEP) meeting to document the team’s decision to refer the student for a behavioral intervention assessment. 2. Complete the Assessment Plan form (D/M 66) and mark the appropriate boxes that correspond to observations/interviews, review of any recent assessment and “other” indicating “Functional Behavioral Assessment.” 3. Complete the Authorization for Use and/or Disclosure of Information form (D/M 63) upon receipt of the signed Assessment Plan form (D/M 66), and obtain the parent/guardian signature. Specify the agency’s name, if known. If not, leave the field blank. 4. The parent/guardian should initial each applicable statement listed under the Parental Authorization section of form D/M 66.
Chapter 5 – Supports and Services, Desert/Mountain SELPA As of 10/18/19 D/M SELPA Steering Committee Approval
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