Form Iep -Ab2726, Chd011 - Residential Placement Plan, Mental Health Services Goals Sheet
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2Page ___ of ____ for IEP Dated: ___________
IEP – AB2726 Residential Placement Plan
Student’s Name: _____________________ DOB: ____________
District of Residence: ___________________________________
7-digit CDS code: __ __ __ __ __ __ __
Current Social/Emotional Student Behaviors Justifying Residential Care:
Less Restrictive Alternatives to Placement Discussed at Expanded IEP Team Meeting:
Case Management
Medication Support
Group Therapy
Collateral
Individual Therapy
Day Rehabilitation
Day Treatment
Results of Discussion (Why these options will or will not be appropriate for this student):
Mental Health
Location
Initial
Freq
Duration
Provider
Goal (One Goal is
Service(s)
(e.g., Grp
Date
(e.g., 4x/mo)
(e.g., 120
Required for Each
Home)
min)
Recommendation)
CM
Refer to MHS Goals Sheet
for specific goal for each
Collateral
service
Ind Therapy
NOTE: Duration time
Grp Therapy
includes not only face-to-
face time, but also any
Meds Monitoring
additional required
activities.
Goals of Residential Care
(Note: Global goal is always to improve educational functioning and facilitate reunification back to the home.
:
This section should address specifics needed to accomplish this goal)
Potential Residential Placements Discussed
(Note: Sites discussed have not yet agreed to placement. Sites discussed are options and
:
should other appropriate placements options develop they will be given equal consideration)
Transition Plan (
):
This should represent current plan for student to transition out of current, or planned, residential placement
PERIODIC REPORT: (
)
A periodic report of pupil’s progress will be provided concurrently to the report card.
Date of Scheduled Report Cards: (1) _____________ (2) _____________ (3) _____________ (4) _____________
IEP TEAM SIGNATURES:
Signature verifies that the AB 2726 Residential Assessment, Residential Plan, and MHS Goals Sheet are
approved and incorporated as referenced, as part of this IEP, including conclusions, milestones/goals and service recommendations. SBCDBH
is designated as the lead case manager in regards to residential placement.
Administrator/Designee Signature
Printed Name
Title
Date
DBH Representative Signature
Printed Name
Title
Date
PARENT/GUARDIAN APPROVAL:
_____ (Parent Initials) I have been advised of my rights, including voluntary nature of AB 2726 residential placement.
_____ (Parent Initials) I have received a copy of the Mental Health Assessment
_____ (Parent Initials) I understand the AB2726 is not responsible for costs of hospitalizations or medical services.
_____ (Parent Initials) I understand that it is my responsibility to facilitate medical and dental services as needed.
_____ (Parent Initials) I understand that I am responsible to provide residence for child in case of emergency.
Parent/Guardian Signature
Printed Name
Title
Date
CHD011 (05/07)
Childrens
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