California Legal Referral Services by jle31578

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									                                     Fresno County AB3632 – Chapter 26.5
                                           Pre-Referral Services (form AB3632-PR)
Note: If additional space is needed, please attach a separate page.         STUDENT NAME:

   Service Type                     Provider                   Frequency     Duration         Start Date         End Date
 1. Counseling
 and guidance           Describe the services:
 services
 Please check one of
 the boxes below.
    The IEP Team has determined that the services provided, as described above, have not met the student’s educational needs.
     This service was considered but not provided; IEP Team considers it to be inadequate or inappropriate for
 the following reasons:


   Service Type                     Provider                   Frequency     Duration         Start Date         End Date
 2. Psychological
 services               Describe the services:
 Please check one of
 the boxes below.
    The IEP Team has determined that the services provided, as described above, have not met the student’s educational needs.
     This service was considered but not provided; IEP Team considers it to be inadequate or inappropriate for
 the following reasons:

   Service Type                     Provider                  Frequency      Duration         Start Date         End Date
 3. Parent
 counseling             Describe the services:
 & training
 Please check one of
 the boxes below.
   The IEP Team has determined that the services provided, as described above, have not met the student’s educational needs.
    This service was considered but not provided; IEP Team considers it to be inadequate or inappropriate for
 the following reasons:

   Service Type                     Provider                  Frequency      Duration         Start Date         End Date
 4. Social work
 services               Describe the services:

 Please check one of
 the boxes below.
   The IEP Team has determined that the services provided, as described above, have not met the student’s educational needs.
    This service was considered but not provided; IEP Team considers it to be inadequate or inappropriate for
 the following reasons:

   Service Type                     Provider                  Frequency      Duration         Start Date         End Date
 5. Behavioral
 interventions          Describe the services:

 Please check one of
 the boxes below.
   The IEP Team has determined that the services provided, as described above, have not met the student’s educational needs.
    This service was considered but not provided; IEP Team considers it to be inadequate or inappropriate for
 the following reasons:


I certify that the above is true and correct to the best of my knowledge.



Name of School Psychologist                              Signature                                                Date




AB3632-PR, CR, RF, CR (Rev. 08-2008)
                                   Fresno County AB3632 – Chapter 26.5
                                            Referral Checklist (form AB3632-RC)


                                Student Name:


This referral packet must be received by Fresno County Mental Health (AB3632 Coordinator) within 5 days of the
date that the school district received a signed parental consent for this referral.


1. Please check to confirm that all items below are included in this referral packet. (All items in this section are required).

       Referral Checklist (form AB3632-RC)                                              Yes              No

       Referral Form, fully completed (form AB3632-RF)                                  Yes              No

       Pre-Referral Services (form AB3632-PR)                                           Yes              No

       Consent for Referral signed by parent/guardian (form AB3632-CR)                  Yes              No

       Copy of most recent IEP including:
                  all pages of IEP document, including addendums/attachments            Yes              No
                  all required signatures on IEP signature page                         Yes              No
                  clear language in IEP indicating referral for AB3632 assessment       Yes              No

       Copies of all current assessment reports completed by school                     Yes              No
        personnel or other agencies, including psychological and
        psychoeducational reports (within the last 3 years)

2. Please check all additional items included in the referral packet. (Although optional for inclusion in the
   referral packet, these items are very helpful in the assessment process).

       Behavior Support Plan                                                            Yes              No

       Academic reports (Grades, Progress Reports, etc.)                                Yes              No

       Health evaluation                                                                Yes              No

       Attendance records                                                               Yes              No

       History of schools attended                                                      Yes              No

3. Is this referral regarding a student who is transferring from another county?         Yes              No
   If yes, please identify the previous county:



                                  Fresno County Mental Health Use Only
   Date Referral Received                                        Outcome of Referral Review
          (date stamp by OA)
                                       Referral accepted. Date:____________ Notified parent              Notified school
                                       Referral incomplete. Missing:_________________________________________
                                       If missing items were not obtained, returned to district. Date: ________________
                                       No assessment is needed or referral is inappropriate.
                                       Explanation:_______________________________________________________
                                       Returned to district. Date:______________

Additional Notes:___________________________________________________________________________________
_______________________________________________

AB3632-PR, CR, RF, CR (Rev. 08-2008)
                                   FRESNO COUNTY AB3632 – CHAPTER 26.5
                            REFERRAL FORM – MENTAL HEALTH ASSESSMENT (Form AB3632 – RF)


Date of Referral:

Referral Contact Person:
                                                      NAME                              TITLE                PHONE NUMBER


Student and Parent Information:

Student Name:                                                                           Date of Birth:

Parent Name:                                                        Home Phone:                    Other Phone:

Address:                                                            Parent’s Primary Language:

Parent Name:                                                        Home Phone:                    Other Phone:

Address:                                                            Parent’s Primary Language:

If student’s caregiver(s) is not the parent:
     Foster Parent        Group Home         Legal Guardian             Other:

Educational Rights Belong to:

If this student is placed in a foster home or group home, please complete this section:

   County of origin:                                           Placing agency:

   Contact person:                                             Phone:

If this student was adopted, please complete this section:

    Does the parent receive Adoption Assistance Program benefits?                 yes         no

    If yes, what is the county of origin for the adoption:

Other Agency Involvement:

Please indicate any current and previous involvement with the following agencies or service providers:

Central Valley Regional Center         Yes    No               Name of Worker:

Phone:                      Describe the student or family’s involvement with CVRC:



Juvenile Probation Department          Yes    No               Name of Probation Officer:

Phone:                      Describe the student or family’s involvement with Juvenile Probation Department:



Child Protective Services       Yes      No                    Name of Social Worker:

Phone:                      Describe the student or family’s involvement with Child Protective Services:



Private or Public Mental Health Services Provider        Yes      No      Name of Provider:

Phone:                      Describe the student or family’s involvement with Mental Health Services Provider:
AB3632-PR, CR, RF, CR (Rev. 08-2008)
Other Agency or Service Provider        Yes     No           Name of Provider:

Phone:                      Describe the student or family’s involvement with Other Agency or Service Provider:



Referral Information:

1   a. Please describe the student’s emotional/behavioral characteristics which prompted this referral:




    b. Describe the specific ways in which these characteristics impede the student from benefitting from
    educational services:




    c. Specify the significance of these characteristics as indicated by their rate of occurrence and intensity:




    d. Identify the qualified educational staff who have observed these characteristics:




    e. Identify the educational and other setting(s) in which these characteristics have been observed:




    f. Describe whether or not these characteristics are associated with a condition that can be described solely
    as a social maladjustment as demonstrated by deliberate noncompliance with accepted social rules or a
    demonstrated ability to control unacceptable behavior:




    g. Please describe whether or not these emotional/behavioral characteristics are associated with a condition
    that can be described as a temporary adjustment problem that can be resolved with less than three months of
    school counseling:



AB3632-PR, CR, RF, CR (Rev. 08-2008)
  In order to make an AB3632/Chapter 26.5 referral, the student’s functioning, including cognitive functioning,
2
  must be at a level sufficient to enable the student to benefit from mental health services. Please provide an
  explanation of the student’s cognitive ability and indicate where in the educational assessments the cognitive
  ability is documented.




3
    Please provide any additional information (if not referenced elsewhere in the referral packet) which is pertinent
    to this referral for AB3632 Mental Health Assessment:




AB3632-PR, CR, RF, CR (Rev. 08-2008)
                                             AB3632- Chapter 26.5
               Parent/Guardian Consent for Referral to Fresno County Mental Health (form AB3632-CR)

    1. The IEP Team has identified that your child may have mental health symptoms which impact his/her ability to
       benefit from special education.

    2. If you consent to a referral, your child may be assessed by a mental health clinician to determine if mental health
       symptoms are impacting his/her ability to benefit from special education.

    3. Fresno County Mental Health (FCMH) will review the referral packet and make a determination as to whether an
       assessment is necessary; if the referral is accepted you will be asked by FCMH to review and sign a separate
       assessment plan and consent form.

    4. After receipt of a signed assessment plan, the FCMH clinician will meet with you and your child for an assessment
       interview and may also observe your child at school.

    5. A report and recommendation from the clinician will be sent to you and the school; if you disagree with the
       recommendation, you may require the clinician to attend the IEP meeting.

    6. If your child is determined to meet criteria for AB3632 mental health services, those services may be
       recommended as part of his/her IEP; an IEP meeting must be held to authorize the recommended services and
       treatment cannot begin until after that meeting.

    7. AB3632 services are voluntary, provided at no charge to you, and are only provided by FCMH staff; if your child is
       receiving private mental health services or if you wish to pursue private mental health services, these are not
       typically covered by the IEP under AB3632.

    8. AB3632 services may include individual therapy, family therapy, group therapy, case management, psychiatry
       services (medication monitoring), and mental health rehabilitation services. Crisis services and the cost of
       medications are not covered.

    9. If AB3632 services are authorized through the IEP, a FCMH clinician should be invited to any future IEP meeting
       in which those services will be discussed.

    10. FCMH will request an IEP meeting at any point when a change or dismissal of services is recommended; this
        would include, but not be limited to, reasons such as treatment goals have been met, treatment recommendations
        have changed, or the student is not participating in or benefitting from treatment.
I have read or had explained to me the above information about AB3632 services. I hereby give my permission for the
IEP Team to refer my child for a mental health assessment, and to exchange appropriate educational, medical, and
psychological information concerning my child with FCMH. I also give my permission for FCMH to observe my child in the
educational setting during school hours. I understand that the results of any assessment will be reviewed with me prior to
the IEP meeting in which these recommended services will be discussed.




Student Name (Please print or type)




Parent/Legal Guardian Name (Please print or type)




Parent/Legal Guardian Signature                                                      Date


AB3632-PR, CR, RF, CR (Rev. 08-2008)
                                       AB 3632/IEP NOTICE


THERAPIST (CMH) NAME:


DATE OF IEP
MEETING:


TIME OF IEP
MEETING:


LOCATION OF IEP
MEETING:


PSYCHOLOGIST NAME:



CONTACT
INFORMATION:

OTHER:




AB3632-PR, CR, RF, CR (Rev. 08-2008)

								
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