RICHMOND PUBLIC SCHOOLS

[Pages:5]TO BE COMPLETED BY THE PARENT ONL Y

Student Name School Student's Address City/ State

RICHMOND PUBLIC SCHOOLS Request for Homebound Instructional Services

2016-2017

Date of Birth

Grade

Age

RPS ID#___________

Zip

Home Phone

Cell Phone

Work Phone

Parent/Legal Guardian Name

Parent/Legal Guardian's Authorization (required):

I am requesting/authorizing homebound instructional services for the above named student. I also give permission for my health care provider to release medical records/information if requested.

Parent/Guardian Signature

Date

TO BE COMPLETED BY THE HOMEBOUND SITE COORDINATOR ONLY

SCHOOL STAFF PLEASE COMPLETE THE FOLLOWING (MANDATORY):

Homeroom Teacher

Counselor

Course Course Course Course Course Course

Instruction is needed in the following course(s):

Classroom Teacher's Name: Classroom Teacher's Name: Classroom Teacher's Name: Classroom Teacher's Name: Classroom Teacher's Name: Classroom Teacher's Name:

Medical Referral Forms Given to Parent All Information Above Has Been Verified School Concurs With Need Student has an IEP Student has a 504 Plan

YES

NO

Form Completed by:

Date:

School Administrator's Acknowledgement of Request: Date:

______ (signature required)

Please forward completed forms to the Homebound Program Coordinator at the address below. Incomplete forms will be returned without being processed.

To be completed by Homebound Coordinator: Request for Homebound Services is approved: YES NO Homebound Coordinator: _______________________________ Date: _____________

Office of Pupil Personnel Services Revised 5/31/2016 ? HLM III

301 N. Ninth Street, 13th Floor, Richmond, VA 23219-1927 Phone: (804) 780-7811, FAX: (804) 780-5175

RICHMOND PUBLIC SCHOOLS Request for Homebound Instructional Services

2016-2017

Homebound Instruction Medical Certification of Need

Homebound instruction shall be made available to students who are confined at home or in a health care facility for periods that would prevent normal school attendance (8VAC20-131-180). The term "confined at home or in a health care facility" means the student is unable to participate in the normal day-to-day activities typically expected during school attendance; and, absences from home are infrequent, for periods of relatively short duration, or to receive health care treatment. Students receiving homebound instruction may not work or participate in extra-curricular activities, non-academic activities (such as field trips), or community activities unless these activities are specifically outlined in the students medical plan of care or the Individualized Education Program (if applicable).

Ts12t..ouNNdbeaaenmmctoeefmooorffptSSlhetctuehedodceoonbln:ty:d__it_th_i_oe__n_l_i_cf__oe__rn__s_w_e_dh___i_pc__hh__y_s_se__ir_c_vi__ai_c_n_e_s_o__ra__r_l_ie_c__er_ne__q_s_eu__d_e_s_c_t_le_i_nd__.i__c_a__l__p___s_y__c__h__o__l_o__g__i_s__t_*___p___r_o__v__id_G_inr_ag_d_ce_a:__r_e___t__o__t__h__e____ 3. Nature and extent of illness: ___________________________________________________________ H__o_m_e_b_o_u_n_d__in_s_t_ru_c_t_io_n__is__d_e_si_g_n_e_d_t_o_p_r_o_v_i_d_e_c_o_n_ti_n_u_i_ty__o_f _e_d_u_c_a_ti_o_n_al__se_r_v_ic_e_s_b__et_w_e_e_n__th_e__cl_a_s_sr_o_o_m___ a_n_d__th_e__h_o_m_e__s_et_t_in_g__o_r _h_e_a_lt_h_c_a_r_e_f_a_ci_l_it_y_f_o_r_s_tu_d_e_n_t_s_w_h_o_s_e__m_e_d_i_c_al_n_e_e_d_s_,_b_o_t_h_p_h_y_s_ic_a_l_a_n_d_________ p4s. yDchaoteloogficeaxla,mcoinatrtaioindoicradtieasgcnhoosoisl oatftethnidsainllcneesfos:r _a_l_im__it_e_d__p_e_r_io_d__o_f_ti_m__e._H__o_m_e_b_o_u_n_d__in_s_t_ru_c_t_io_n__is___ n5o. tIisntheendsetuddteonrtecpolnacfientehdeartehgoumlaer socrhionoal chuerarlitchucluarme,fancdiliitsy?thereYfoErSe, not Na Oguarantee that the student will p6r.oIgsrethses inllntheessa/tcraedaetmmeicntpirnotgerammit.tent in nature (e.g., sickle cell anemia, chemotherapy for

childhood cancer)? YES NO 7. Could this child attend school if accommodations are made by the school? YES NO

If yes, please list the accommodations required. If no, please explain ___________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 8. Estimated date of return to school: _______________________________________________________ 9. Explain ongoing treatment and/or therapy being provided:____________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 10. Frequency of treatment: ______________________________________________________________

___________________________________________ _____________________

Signature of Licensed Physician/Clinical Psychologist

Date

______________________________________________ _________________________

Print Physician/Psychologist Name

Telephone Number

__________________________________________________________________________________

Office Address

City, State and Zip Code

(OVER)

Office of Pupil Personnel Services Revised 5/31/2016-HLM III

301 N. Ninth Street, 13th Floor, Richmond, VA 23219-1927 Phone: (804) 780-7811, FAX: (804) 780-5175

RICHMOND PUBLIC SCHOOLS Request for Homebound Instructional Services

2016-2017

Students may receive instruction in the home, a health care facility, or any other approved facility as agreed upon by the school division and parent or student who has reached the age of majority (eligible student). If it is necessary for homebound instruction to continue beyond nine weeks, an extension or reaTuothboericzoamtiopnleftoerdmb, yintchluedpianrgetnret/agtmuaerndtipalnano,rperoliggribeslse tsotuwdaerdnst.treatment goals, and specific plans to transition the student back to the school setting, will be required.

Name of Parent/Guardian or Eligible Student: _______________________________________ Home Phone: __________________________ Work phone: _______________________ Cell Phone: ___________________________ Street Address: ________________________________________________________________ City:___________________________________ State:_________ Zip Code:_______________

Acknowledgement/Release: I acknowledge this request and agree with the need for homebound services. I further acknowledge that the requested homebound services for students receiving special education services shall be subject to review by the student's IEP team pursuant to the Individuals with Disabilities Education Act. I will provide an environment conducive to learning, ensure that a responsible adult is in the home for the duration of instruction, or provide transportation to another agreed upon facility. I will keep appointments with the homebound teacher or contact the teacher or homebound coordinator if an appointment must be missed.

I understand that the local school division has established policies and procedures for homebound instruction that provide more detail than this certificate of need.

* The Code of Virginia ? 54.1-2957.02 states "whenever any law or regulation requires a signature,

ceBrtiyficmatyiosni,gsntaamtup,rev,erIifaicuatthioonr,iazfefidthaveitreolreeansdeorasnemdeenxt cbhyaanpgheysoicfiamn,eidt ischaalllibnefodermemaetdioton ibnceltuwdeeean the health sigcnaarteurper, ocevritdifeicra,tiloisnt,esdtamonp,tvheerirfiecvateirosne, asfifdidea,voitrohr iesn/dhoerrsedmeesnigt bnyeea,naunrsde spcrahcotiotilondeirv."ision personnel. My

signature provides the heath care provider(s) with the authorization necessary to disclose protected health information and records regarding said student. This authorization may be withdrawn at anytime in writing.

Please note: This form, including parental permission to contact the treating physician or

psychologist, must be fully completed in order for the student to be considered for

homebound services. If you have questions about completing this form, please contact:

The Office of Pupil Personnel Services, (804) 780-7811 or (804 780-7780.

_______________________________________________ ___________________

Signature of Parent/Guardian or Eligible Student

Date

Office of Pupil Personnel Services Revised 5/31/2016 ? HLM III

301 N. Ninth Street, 13th Floor, Richmond, VA 23219-1927 Phone: (804) 780-7811, FAX: (804) 780-5175

DATE

RICHMOND PUBLIC SCHOOLS Request for Homebound Instructional Services

2016-2017

TREATMENT PLAN

(Form to be completed by parent and Physician)

Name of Student School Parent's Name Student's Address ICD9/DSM IV Diagnosis Nature and extent of disability

Date of Birth

Age

Phone

TREATMENT PLAN RECOMMENDATIONS

TO BE COMPLETED BY THE STUDENT'S PHYSICIAN ONLY

PSYCHOTHERAPY

MEDICATION MANAGEMENT

ONGOING ASSESSMENT AS TO READINESS TO RETURN TO SCHOOL

EXPECTED DATE OF RETURN TO SCHOOL

ADAPTATIONS IF NECESSARY: 1. 2. 3.

LICENSED CLINICAL PSYCHOLOGIST/ PSYCHIATRIST'S AUTHORIZATION

Type or print physician's name

Address

Zip Code

Business phone

Business Fax

Physician's Signature

Date

Office of Pupil Personnel Services Revised 5/31/2016 ? HLM III

301 N. Ninth Street, 13th Floor, Richmond, VA 23219-1927 Phone: (804) 780-7811, FAX: (804) 780-5175

TO BE COMPLETED BY THE HOMEBOUND SITE COORDINATOR ONLY

RICHMOND PUBLIC SCHOOLS Request for Homebound Instructional Services

2016-2017

Homebound/Home-based Instruction Student Information Sheet

Directions: This information sheet is to be completed by a school Guidance Counselor or Homebound Site Coordinator and sent to the Office of Pupil Personnel Services no later than two 2) school days after the receipt of the Request for Homebound Services Forms and Medical Referral Forms from the parent(s).

Student Name: ___________________________ DOB: ____________ RPS ID#: __________

School: ______________________________ School Year: _____________ Grade: ________

School contact / title: _____________________________________ phone: _______________

Does this student have an IEP or 504? YES / NO (If "yes", attach IEP)

Date of current IEP/504: ____________ Date of last Eligibility: _____________

List courses enrolled and current grades:

Course No.

Subject

(Specific Course Name, e.g. Algebra II)

Grade

(Percent only)

RPS Grading Scale

A 100-90 B 89 ? 80 C 79 ? 70 D 69 ? 60 F 59 ? 0

Indicate how student will be tested in each content area (SOL, VGLA, VAAP, or N/A):

(If student has an IEP, refer to the testing page.)

Reading

Mathematics

Science

History/Social Science

Please provide any other information which may be relevant for the Homebound/Home-based teacher including but not limited to general demeanor, class behavior, interactions with peers, family issues: _______________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Office of Pupil Personnel Services Revised 5/31/2016 ? HLM III

301 N. Ninth Street, 13th Floor, Richmond, VA 23219-1927 Phone: (804) 780-7811, FAX: (804) 780-5175

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