UNIQUE ALTERNATIVE INITIAL APPLICATION by E6nn41uw

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									                                    UNIQUE ALTERNATIVE INITIAL APPLICATION
                                                                     2009-2010
                                                       PART I - CASE HISTORY

Name of Student:                                                                        Date of Application:

Date of Birth:                               Chronological Age:                                  Exit Year:
                        Mo./ Day/Year                                          Years-Months


Race:                   1             2         3           4             5         Other:
1-American Indian, 2-African American, 3-Asian, 4-Hispanic, 5-Caucasian

School District of Residence:

CURRENT DISABILITY CONDITION(S):

               Educational:

                    DSM IV:

                     Medical:

               Legal Status:

PARENTS/GUARDIANS:

                       Name:

                    Address:

                            City:                                    State:          Zip:                 Phone:


Interagency Consent to Release Information form attached:                                          Yes                No*
                                    (* Application cannot proceed to ICT without Release Form.)


                                      District Verification for Unique Alternative Support

                                                            has needs that cannot be addressed through the existing
              (Student Name)
resources/programs of the state.

The completed application, including appropriate assessment, educational data and a current Individual Education
Program (IEP) are attached. In addition, an Interagency Consent to Release Information form is attached.

                                                                     (Signature)              District:
District Supervisor/Director Of Special Education, or
Designee In Charge Of Unique Alternative Applications

                                                                     (Signature)                Date:
District Chief School Officer


2/16/06
I.            AGENCY INVOLVEMENT
Identify representatives of All Agencies and service providers involved with the student:
Specify the services provided (if any):

LEA: Name                  _____________________________________________________________________________

Current Grade:             ______________ School: _________________________                 Program: ___________________

Grade and School in September 2006:          _______________________________________________________________

Contact Person/Title:      ____________________ Telephone Number: ________________________

Agency              Yes     No     Referral in   Service Provided           Contact Name            Agency SLC
                                    Progress



DSCYF (CMH)



DSCYF (YRS)



DSCYF (DFS)



DHSS
(DSAMH)


DHSS (DDDS)



DHSS (DVI)



DVR



Private Service
Provider


Other



FACT Project




                                                              2
3/3/06 FY07
II. INDIVIDUAL FUNCTIONAL CAPACITIES

     A.         FORMAL ASSESSMENTS
     Provide required formal assessment information stated below to assist the Interagency Collaborative Team
     (ICT) in understanding the individual. Please include any other formal assessment information that is relevant.

              REQUIRED                                                         AS APPROPRIATE
 ■     Intelligence/Cognitive                                         ●   Speech/Language Evaluation
 ■     Achievement                                                    ●   Hearing Evaluation
 ■     Behavior Rater                                                 ●   Vision Evaluation
 ■     Vocational Evaluation for Youth 15 and older                   ●   Occupational Therapy Evaluation
 ■     Basic Medical Evaluation                                       ●   Physical Therapy Evaluation
                                                                      ●   Other medical evaluations
                                                                      ●   Psychiatric Evaluation
                                                                      ●   Social Adaptive Behavior Scales


 NAME/TYPE OF ASSESSMENT                                      SCORES/RESULTS                                DATE




     B. INFORMAL ASSESSMENTS
     Provide additional observational assessment information to help the Interagency Collaborative Team (ICT)
     understand the current functioning level of the individual. This might include:

              Reading instructional level
              Math instructional level
              Functional academic skills
              Survival skills
              Functional independent living skills
              Functional language/communication skills
              Functional gross/fine motor skills
              Work adjustment skills, functional vocational skills
              Functional Behavior Assessment


     C. PSYCHOSOCIAL HISTORY
     Include a family history that indicates relevant information. Indicate the involvement of agencies and other
     supports available for this family.

     (Note: If a comprehensive psychosocial history is available in supporting documentation please indicate the title of the
     document and date.)




                                                                      3
3/3/06 FY07
       D. MEDICATIONS

       Provide a list of medications that the student is currently taking (including psychotropic medications).


              MEDICATIONS                                  DOSAGE                     PRESCRIBING PHYSICIAN




III. HISTORICAL INTERVENTION/PLACEMENT HISTORY/TREATMENT HISTORY
                           SIGNIFICANT LIFE EVENTS

Specify by date in chronological order the placement location and the types of support (levels of service) provided.
Also, include each significant life event.                 (Provide as an attachment, if necessary.)

        DATE                    LOCATION                   SUPPORT/LEVEL/SIGNIFICANT LIFE EVENT




                                                             4
3/3/06 FY07
IV. INDIVIDUALIZED EDUCATION PROGRAM

Attach a copy of the individual’s current IEP. Include copies of meeting minutes relevant to referral. For students
14 years of age and older the IEP must include a transition plan.

V. STUDENT/FAMILY STRENGTHS AND NEEDS

        A. Please state the following:

              INDIVIDUAL'S STRENGTHS                                     INDIVIDUAL'S NEEDS




                  FAMILY’S STRENGTHS                                        FAMILY’S NEEDS




     B.       The presenting problem(s):




     C.       Does this child’s behavior present a risk to him/herself?                  Yes             No
              If yes, please describe:




              Does this child’s behavior present a risk to others?                      Yes              No
              If yes, please describe:




                                                          5
3/3/06 FY07
     D. What significant interventions have been implemented? Please include data.




     E.       What are the long-term goal(s) and valued outcomes for this individual?




     F.       What would have to change for the student and/or school in order to support this child
              within his/her home district?




     G.       What is the anticipated duration of the Unique Alternative Support? Include transition plans
              that would allow Unique Alternative Support/Services to fade.




VI. UNIQUE ALTERNATIVE SUPPORT

                                          UNIQUE ALTERNATIVE                  MEASURE OF IMPACT-
       STUDENT’S NEEDS                     SUPPORT/SERVICES                      BE SPECIFIC




                                                       6
3/3/06 FY07

								
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