INDIVIDUAL SERVICE PLAN FOR
PARENTALLY PLACED PRIVATE SCHOOL STUDENTS
1.
Student Name: Enter the student’s last name and
first name.
2.
DOB: Enter the student’s date of birth.
3.
Grade: Enter the student’s current grade
level.
4.
Parent / Guardian Names: Enter the name(s) of the parent(s)
or guardian(s).
5.
Address: Enter the student’s current
address. If the student is living in a
residential school, enter the address of the parent.
6.
Home Phone: Enter the
phone number of the parent(s) or guardian(s).
7.
Cell Phone: Enter the cell number of the
parent(s) or guardian(s), if known.
8.
Work Phone: Enter the work phone of one of the
parent(s) or guardian(s), if known.
9.
District where private school is
located: Enter
the name of the district where the private school is located (unless other
agreements have been made. This would be
the district drafting and implementing the Service Plan.
10.
District of residence: Enter the name of the district
where the student’s parent(s) or guardian(s) reside.
11.
12.
Private School: Enter the name of the private
school where the student is currently attending.
13.
Private School Phone: Enter the phone number of the
private school.
14.
District of Residence Phone: Enter the phone number of the
District of Residence listed on the Service Plan (item 10 above).
15.
Check the following: Check ONLY one of the following:
Student’s parent(s) or guardian(s)
have declined the district’s offer of a Service Plan – check this option if the
parent(s) or guardian(s) have declined wanting a service plan. This would be applicable
if they want no services or if at some time they choose to enroll the student
in a public school program in the district of residence.
Student’s parent(s) or guardian(s)
have accepted the district’s offer of a Service Plan.
16. Services: Enter the special
education service(s) below for the student while enrolled in private school or
until the proportionate share of federal funds have been expended for the
current school year.
17. Area(s) or need: Enter the
area(s) of need based on the assessment results.
18. Summary of Present Levels: Enter
the present levels in relevant areas assessed (social / emotional, academic,
etc.).
19. Enter the service(s): Enter the
service(s) being offered. Remember, the
services offered must be based on the final decisions the SELPA / District have
made with respect to private school services. (§300.320)
20. Frequency: Enter how often the
service will take place or how many sessions, etc.
21.
Duration: Enter how long (minutes, hours,
etc.) each service will take place.
22.
Location: Enter the location where services
will take place.
23.
Start Date: Enter the date when services will
being.
24.
End Date: Enter the date when services will
end.
25.
Service Provider: Enter the “title,” not the name,
of the service provider.
21.
Signature Lines: Parent – have the parent sign in attendance.
LEA Representative – enter the
name of the person who is representing the district/LEA. Remember this person
must have the authority to allocate services.
Other –
have any other persons in attendance sign the Service Plan.
27. Next
Annual Review Due By: Enter the next annual review date (approximately
one year from the date of the date of the current service plan meeting).
28. Triennial
Review Due By: Enter the triennial review date. This is three years
from the date of the last assessment review or the initial assessment review.