ASSESSMENT TEAM SUMMARY REPORT/ELIGIBILITY STATEMENT/OTHER SERVICES

IEP Date   Student Name
 

Other Agency Services
 
California Children's Services (CCS) Regional Center
Probation Department of Rehabilitation
Department of Social Services (DSS) Other:
   
 

Data Collection for Mental Health (AB3632)
 
Is the student eligible for Mental Health Services under CH 26.5 (AB3632)?
Is a Mental Health CH 26.5 AB3632 Services Plan attached to the IEP and services documented above?
Is the CH 26.5 AB3632 Service Plan accepted by Parent or Adult Student?
 

Specific Learning Disabilities Only
 
Student   meet CCR Title 5-Section 3030J Criteria for Specific Learning Disabilities.
   
  A severe discrepancy between intellectual ability and achievement is demonstrated in one or more of the following area(s):
    Listening comprehension Basic reading skills Mathematics calculation
    Oral expression Reading comprehension Mathematics reasoning
    Written expression    
      AND  
  A disorder is demonstrated in one or more of the following basic psychological processes:
   
Auditory processing Visual processing Sensory-motor skills Attention
Cognitive abilities Conceptualization Association Expression
 

Comments:
 
 
Revised 8/2008