Special Education Local Plan Area ______A Joint Powers Agency
Santa Barbara County
Special Education Local Plan Area ______A Joint Powers Agency
OT Referral Steps Checklist
TO: SPECIAL EDUCATION DIRECTORS
FROM: OCCUPATIONAL THERAPY PROGRAM
RE: OCCUPATIONAL THERAPY REFERRAL
Student Name: ______
DOB: ______
District: ______
Referral Steps for Regional Occupational Therapy Services:
1. (Check one that applies)
The student is presently enrolled in a Special Education Program. He/she has been referred for O.T. because he/she may require this service in order to benefit from his/her Special Education program.
Or
The LEA determines OT is an area related to the suspected disability and an OT assessment is written in to an initial assessment plan. (34 CFR 300.301).
Or
The parent requests an OT assessment and the district agrees to the assessment.
Or
A student transfers into a school district from another SELPA with a current IEP which includes school-based OT as a related service.
2. The referring LEA administrator or designee completes the SELPA OT Referral Packet.
The Referral Packet includes: (Special Education Administrator should check off each box when document is attached))
a. SELPA55: OT Referral Steps Checklist
b. SELPA56: Motor/Sensory Student Profile Checklist form. Include documentation of prior interventions by school staff to address needs impacting educational benefit.
c. SUPP21A: Referral for Special Education and Related Services form
Make sure to complete the section of “general education interventions attempts.”
Include specific information in this section with added pages if needed.
d. SELPA3: Parent Consent for Release of Information form (This form is not required but recommended)
e. SELPA6: OT Physician’s Cover Letter (This form is not required but recommended)
f. SELPA16: Physicians Information Form for Related Services or memo from Special Education Administrator stating that they have reviewed student’s file and not found any CCS medically eligible conditions in documentation (This form is not required but recommended)
g. Copies of Current IEP and the most current related evaluations (psychological, speech, APE, resource), if they exist.
h. CCS Denial or Release from services letter (This form is not required but recommended) (with NA in box if not appropriate).
3. Referring LEA Administrator or designee must review referral prior to sending to the OT Regional Program Operator. The LEA has the obligation to process paperwork and provide the referral to the regional operator in a timely fashion so the regional operator can send the assessment plan within 15 days of the date of referral.
4. If CCS eligible, referral to CCS, (this eligibility can not hold up the LEA’s OT referral process) ensuring that packet contains information required for CCS referrals. (See 2 CCR 60320(c). The referral to CCS cannot delay the educationally-related OT referral. Medically necessary OT has no bearing on the LEA’s obligation to meet the 15 day timeline to offer an assessment plan to the parent for an educationally-related OT assessment.
Note: If not CCS eligible or LEA does not have confirmation of CCS eligibility within a week of receipt of referral, continue the SELPA referral process. Note: The LEA has 15 days from receipt of a referral for assessment, to either send an assessment plan or send a prior written notice to the parent declining assessment and detailing the reason why the request is being denied.
5. Send Referral Packet to the Following:
North/Lompoc: South/Valley
Lana Thomas OT Coordinator
Director, Pupil Services County Education Office
500 Dyer St P.O. Box 6307
Santa Maria, CA 93455 Santa Barbara, CA 93160-6307
Questions: 805-938-8960 Questions: 805-964-4711 x5421
______
Date Sent by LEA Signature of Date Received by LEA SPED Administrator Regional Program Operator
(Reviewed all forms and checked boxes)
DATE APPROVED: 2/1/2010
SELPA 55 7/20/2016 Page 1 of 2