Non-Medical Referral For Interim Home Instruction Form
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1A COPY OF IMMUNIZATION RECORDS ARE REQUIRED WITH THIS REFERRAL
BUL- 1229.2
Page 1 of 1
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
NON-MEDICAL REFERRAL FOR INTERIM HOME INSTRUCTION
NOTE: Home Teaching is considered a change in placement. Where applicable attach a copy of the current IEP page
which indicates interim placement to Home Teaching and the anticipated ending date of service. Placement may not
exceed 60 calendar days without a review of the current IEP.
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 _____
School of Residence ______________________________ Local District _____
□
□
Does student have a current IEP?
Yes
No
Eligibility__________________
Indicate Service Requested:
□
HOME TEACHING
Questions: Call Administrator, Carlson Home Hospital School at (818) 509-8759.
Fax referral to Carlson Home Hospital School at (818) 505-0246
Reason for Referral:
Additional Comments:
Non-Medical Referral form completed by:
__________________________
_____________________
__________________________
________________
Print Name
Print Title
Phone Number
Date
Requested beginning date of service: ___________________ Anticipated ending date as indicated on IEP ____________
60
(Referral not to exceed
days)
NON-MEDICAL REFERRAL MUST BE AUTHORIZED BY THE SPECIAL EDUCATION SUPPORT UNIT
ADMINISTRATOR OR THE COORDINATOR OF NONPUBLIC SERVICES DEPARTMENT
SPECIAL EDUCATION SUPPORT UNIT ADMINISTRATOR OR
NPS DEPARTMENT COORDINATOR AUTHORIZATION
_____________________________ _____________________ __________________________ _____________
Print Name
Print Title
Signature
Date
C:/Documents and Settings/lauds_user/Desktop/REFERRALS
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