A COPY OF IMMUNIZATION RECORDS ARE REQUIRED WITH THIS REFERRAL
Page 2 of 2
PSYCHIATRIC REFERRAL
PSYCHIATRIC REFERRAL
Student Name ________________________________________
D.O.B __________________________
PSYCHIATRIST: A request for Home Instruction has been made for the above-named student. The California Education
Code §44873 requires that a licensed California physician file a statement which includes a medical diagnosis.
Attending Psychiatrist’s Statement
Is student capable of attending classes on his/her school campus now, with accommodations to meet
□
□
their emotional needs?
Yes
No
If yes, please list accommodations:
If no, please complete the information below:
DSM IV Diagnosis:
Summary of Therapeutic Plan:
What medication(s) is/are the student currently prescribed?
□
□
Is the student a danger to self or others:
Yes
No
Explain:
Why is the student unable to attend school?
What aspects of the treatment plan are being implemented to enable the student to return to school?
□
□
Estimated date student may return to school: __________________________________
Part time
Full
60
time (Referral not to exceed
days)
Physician’s Signature ______________________________________ M.D.
Date ___________________
Physician’s Name (Print) _______________________________ M.D. Phone: (
) __________________
Fax: (
) __________________
Address____________________________________ City______________________ Zip ______________
C:/Documents and Settings/lauds_user/Desktop/REFERRALS