Appendix D

AB 2726 & 26.5 COUNTY DEPARTMENT OF BEHAVIORAL HEALTH
MENTAL HEALTH PORTION OF THE IEP
 
 
Student's Name ,   IEP Date
  Appendix D Date Appendix D Date Pick a date
 

 
I. DESCRIPTION OF THE STUDENT’S PRESENT LEVEL OF SOCIAL AND EMOTIONAL PERFORMANCE (What are the barriers to the student benefiting from his or her education):  
 
 
II. GOAL # 1 (expressed in observable, behavioral, and measurable terms and related to present level of performance):  
 
 
  Objectives (activities or interventions to achieve goal):  
 
 
  Goal # 2:  
 
 
  Objectives:  
 
 
III. Progress toward these goals will be evaluated by using student, parent, and teacher reports along with performance outcome assessment instruments, as appropriate. Progress reports will be provided to the parents and LEA as indicated in the IEP.  
 
 
IV. MODALITY OF SERVICE, LOCATION AND FREQUENCY: (may include: individual therapy, group therapy, family therapy; collateral services, medication support services, or case management services)  
 
 
V. INITIATION AND DURATION OF MENTAL HEALTH SERVICES: These services are to start once the parent agrees upon this IEP plan and will continue for the length of time indicated on the IEP. The services are to be available as indicated, but they may be increased by agreement among the student, the parent, and the primary clinician with input from school personnel.

When completion or termination of IEP specified mental health services is mutually agreed upon by the parent and the DBH, or when the pupil is no longer participating in treatment, DBH shall notify the parent and the LEA, which shall schedule an IEP team meeting to discuss and document this proposed change if it is acceptable to the IEP team.
 
 

 
  Signatures  
 
 
 
  Parent   Date
 
 
 
  Student   Date
 
 
 
  DBH Representative   Date