SELPA Referral Procedures
LEAs participating in the SELPA Audiological Program may request an annual audiological assessment by following the procedure listed below. It is not necessary that the IEP team convene for this type of referral. a) Complete the Annual Request for Audiological Evaluations/Services form (DM 108A) . Please DO NOT complete the Initial Request for Audiological Evaluations/Services form (DM 108) for annual referrals. 1. Include information that is related to the school of attendance, program placement, and services the student is current receiving.
2. Include behavior and/or academic successes or challenges.
3. Include information regarding the use and functioning of equipment such as hearing aids and/or FM systems.
4. Inc lude medical information related to the student’s hearing.
b) Complete the Assessment Plan form (DM 66) and obtain the parent/guardian signature.
1. The person making the referral should check the box that corresponds to the type of assessment(s) requested. Most often the “other” box is checked followed by the statement, “Audiological assessment to be completed by SELPA contracted audiologist.” 2. The parent/guardian should initial each applicable statement listed under the Parental Authorization section of form DM 66. 3. LEAs are encouraged to have the assessment plan signed close to the date of their LEA audiology evaluation date and within the required 60-day time frame. c) Complete the Authorization for Use and/or Disclosure of information form (DM 63) and obtain the parent/guardian signature. Specify the receiving agency’s name as the SELPA/DMOPs/Pacific Hearing Services. The disclosing agency will vary depending on whether it is a physician, medical center, or audiologist.
2.
Referral Procedures
Forward the following completed documents to the attention of the Area Director for DMOPs.
CAHELP JPA Referral Procedures
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Revised 8/9/2022
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