Montgomery County Public Schools

Application for Interim Instructional Services, with Qualified Mental Health Condition ONLY

Note: This form is used by the Interim Instructional Services (IIS) Office to obtain psychiatrist’s/psychologist’s recommendation and parent/guardian permission to initiate instruction for students with a mental health condition. Return completed application to student’s school counselor or principal/designee.

A new completed application is required for continuation of service beyond 60 calendar days.

Application for Interim Instructional Services, with Qualified Mental Health Condition ONLY	437 K	English
Solicitud para Servicios Instructivos Provisionales, SÓLO con Condición de Salud Mental Calificada	431 K	Spanish
Demande de Services Provisoires d’Éducation, Uniquement pour un Cas de Santé/Condition Physique Éligible	433 K	French
Đơn cho Các Dịch Vụ Giảng Dạy Tạm Thời, CHỈ với Điều Kiện Sức Khỏe Tinh Thần	512 K	Vietnamese
臨時教學服務申請 (僅限於符合條件的心理健康狀況)	542 K	Chinese
임시 교습 서비스 지원서(승인된 정신 건강 상태인 학생용)	462 K	Korean
ለጊዜያዊ የትምህርት አገልግሎት ማመልከቻ፣ መስፈርት ለሚያሟላ ለአእምሮ ጤንነት ሁኔታ ብቻ	456 K	Amharic

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