Individual Service(s) Plan For Voluntarily Enrolled Private School Students
Date*
Date*
(This form can generate more than one printed page)
Student Name
DOB
DOB
Age
Gender
Gender
Social Security #
Social Security #
ID Code
ID Code
CSIS Code
Current Grade
Current Grade
Name of Parent/Surrogate Guardian
Ph: Home
Ph: Home
Ph: Work
Ph: Work
Address
Apt. #
City
Zip
District of Residence
District of Residence
School
School
Private School Enrolled in
Private School Enrolled in
Home Language
Home Language
Student's Language
Migrant Ed
Yes
No
Yes
No
Ethnicity
1
1
2
2
3
3
4
4
5
5
6
6
English Language Learner
Yes
No
Yes
No
Interpreter Required
Yes
No
Yes
No
DATES
Initial Placement in Special Ed.
Initial Placement in Special Ed.
Last Triennial
Last Triennial
Next ISP
Next ISP
PURPOSE OF MEETING*
PURPOSE OF MEETING*
AGENCY SERVICES
California Children's Services (CCS)
California Children's Services (CCS)
Department of Rehabilitation
Department of Rehabilitation
County Mental Health (CMH)
County Mental Health (CMH)
Regional Center
Regional Center
Department of Social Services (DSS)
Department of Social Services (DSS)
Other agency services (specify):
RESIDENCY
RESIDENCY
Other type:
Foster/LCI#.
Pursuant to 20 U.S. C. 1412(a)(10)(IDEA 97) and 34 C.F.R. 300.450 et. seq. and the NCCSE policy, special education and related services will be provided to the student while enrolled in private school as set forth below:
Special education & Related Services pursuant to NCCSE Policy #19
Program Modifications/Support for Private School Personnel (Consultative Services)
Frequency of Service
Duration
Location
Start Date
End Date
Consultation Services by Resource Specialist
Consultation Services by Resource Specialist
(check date)
(check date)
Consultation services by speech/language specialist
Consultation services by speech/language specialist
(check date)
(check date)
Primary Disability Category
Primary Disability Category
Present Levels of Educational Performance
*Required items