Services / ESY Services
Last Name
First Name
Meeting Date
Teacher*
Teacher*
If the teacher is not listed in the pop-up, try entering the name or code here:
School*
School*
If the school is not listed in the pop-up, try entering the school name or code here:
Service*
Service*
Primary
Primary
Yes
No
Yes
No
Report to CASEMIS
Yes
No
Yes
No
Start date*
Start date*
Location type*
Location type*
Provider/responsible agency*
Provider/responsible agency*
End (evaluation) date
End (evaluation) date
Extended school year
Extended school year
Yes
No
Yes
No
Duration (other description)
Duration (other description)
(Describe if other:)
Sessions per week
Sessions per week
Frequency (other)
Frequency (other)
(Describe if other:)
Auxiliary service location
Auxiliary service location
Individual/group
Individual/group
Consult
Consult
Yes
No
Yes
No
LEA district
LEA district
The following items are required for infant and mental health services:
Provider type
Provider type
(*infant/MHS)
Frequency code
Frequency code
(*infant/MHS)
Duration, minutes per session
Duration, minutes per session
(*infant/MHS)
The following items should be specified when the service has been discontinued:
Drop date
Drop reason
Drop reason
(primary service only)
Drop code or reason
Drop code or reason
(non-primary service only)
For information only (no entry here):
Drop date
Primary drop reason
-
Non-primary drop reason
-
*Required items