Form Iep-Ab 2726, Chd005 Outpatient Service Plan - Department Of Behavioral Health, County Of San Bernardino

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County of San Bernardino
Department of Behavioral Health
Page ___ of ____ for IEP Dated: ___________
IEP – AB2726 Outpatient Mental Health Services Plan
Student’s Name: ____________________
DOB: ____________
District of Residence:
7-digit CDS code: __ __ __ __ __ __ __
Current Social/Emotional Student Behaviors Justifying Outpatient Care:
Goals of Client/Parent/Guardian:
Goals of AB2726 Outpatient Services
(Note: Global goal is always to improve educational functioning. This section should
:
address specifics needed to accomplish this goal)
Mental Health Services to be Provided
Duration time includes not only face-to-face time, but also any required additional activities.
Individual Therapy
Loc: _______ Initial Date: _______ Freq: ____ Duration: ____
End Date: _______
Goal for Individual Therapy:
Group Therapy
Loc: _______ Initial Date: _______ Freq: ____ Duration: ____
End Date: _______
Goal for Group Therapy:
Medication Monitoring Loc: _______ Initial Date: _______ Freq: ____ Duration: ____
End Date: _______
Goal for Medication Monitoring:
Collateral
Loc: _______ Initial Date: _______ Freq: ____ Duration: ____
End Date: _______
Goal for Collateral Services:
Other (e.g., CM)
Loc: _______ Initial Date: _______ Freq: ____ Duration: ____
End Date: _______
Goal for this service:
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 Outpatient Services are approved and incorporated as
)
referenced, as part of this IEP, including conclusions, milestones/goals and service recommendations.
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 services.
_____ (Parent Initials) I have received a copy of the Mental Health Assessment
_____ (Parent Initials) SBCDBH (AB2726) is not responsible for costs of medications or other medical services.
Parent/Guardian Signature
Printed Name
Title
Date
CHD005 (05/07)
Childrens
Page 1 of 1
CHD005 (05/07)
Childrens
Page 1 of 1

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