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)?
Yes
No
Yes
No
Is a Mental Health CH 26.5 AB3632 Services Plan attached to the IEP and services documented above?
Yes
No
Yes
No
Is the CH 26.5 AB3632 Service Plan accepted by Parent or Adult Student?
Yes
No
Yes
No
Specific Learning Disabilities Only
Student
does
does not
does
does not
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