Psychiatric Referral Form
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1
2A COPY OF IMMUNIZATION RECORDS ARE REQUIRED WITH THIS REFERRAL
BUL- 1229.2
Page 1 of 2
LOS ANGELES UNIFIED SCHOOL DISTRICT
Educational Options
ATTACHMENT D
Carlson Home Hospital School
December 12, 2011
10952 Whipple St.
No. Hollywood, CA 91602
Phone: (818) 509-8759 FAX: (818) 505-0246
PSYCHIATRIC REFERRAL
HOME INSTRUCTION
Student Information
□
□
Last Name________________________________________ First Name__________________________________
M
F
DOB_________/__________/___________ Gr. ___________ Student Language_________________________
Address _____________________________________________ City______________________________ Zip_______________
Home Phone (
) __________________ Cell Phone (
) _________________ Work Phone (
) __________________
Parent/Guardian ________________________________________ Parent/Guardian Language
__________________________
Cum Carrying School _____________________________ Phone (
) _________________ Track ____ Local District _____
Last date of attendance ______________________
Does student have a current IEP/504 Plan?
Yes
No
Eligibility__________________
The following modified programs or other educational options have been tried (please check all options that apply):
□
Enrolled in a shortened school day.
□
Enrolled in a Independent Study Program allowing the student to complete course work independently, at home, and review
work once a week with a teacher for a grade.
□
Developed and implemented a Section 504 Plan to accommodate student needs through program modifications (ie: modify a
class schedule, adjust placement of a student within a classroom, increase/decrease opportunity for movement, quiet area to
complete work, approve early dismissal for service agency appointments, etc.)
□
Identified as eligible for special education services and an Individualized Education Program (IEP) was developed to consider
the student’s abilities, educational needs, and the appropriate placement and services.
□
Referred to Teleteaching (requires the ability to participate in telephone conferences with peers and instructors)
□
Other: _______________________________________________________________________________________________________
Comments___________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
IMPLEMENTATION OF SERVICE
HOME TEACHING -Carlson Home Instruction will provide five (5) hours of instruction per week in a manner consistent with
California laws governing home teaching. Instruction is offered in two (2) basic subject areas unless additional courses are
approved by a Carlson administrator.
(18 years of age or older)
A responsible adult
must be present when the teacher is in the home.
By signing this authorization for service, the parent/guardian is agreeing to the following:
If the student is eligible, educational services will be temporarily provided by the Carlson Home/Hospital School
►
The student will be temporarily disenrolled from his/her regular school of attendance (cumulative record carrying school) during the
►
period he/she is receiving home instruction or teleteaching. Grades and marks will be reported to the cumulative record carrying school.
Educational information will be accessed and used to plan and provide an appropriate educational program for the student.
►
Permission to provide services or access school records may be revoked via written parent/guardian request at any time.
►
The parent/guardian has the right to receive a copy of this form upon request.
►
PARENT/LEGAL GUARDIAN AUTHORIZATION TO RECEIVE/RELEASE MEDICAL AND
ACADEMIC INFORMATION AND TEMPORARILY TRANSFER EDUCATIONAL DUTIES:
Parent Signature____________________________________ Date: ___________________
California Licensed Psychiatrist must complete page 2 to authorize service
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