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Request for Private Therapeutic Services in School

About this Form

Form number: 273-2

Audience:  Principals

Last revised: October 2018

INSTRUCTIONS: The parent/guardian is to complete the entire form and submit to the principal/designee of the student’s home school. A new request must be submitted each school year.
This request form is used by the school principal/designee to determine whether or not to approve requests from parents/guardians for a private therapist to work with a student at school during the school day. Each provider must be approved to work with a student; and there are no therapists or agencies that have been pre-approved to provide such private therapy services to multiple students*. It is the sole discretion of the principal/designee to approve or deny any request for school visitors in accordance with MCPS Regulation ABA-RB, School Visitors. Parent/guardian requests for private therapists to provide Applied Behavior Analysis (ABA) therapy and other related services (such as speech, occupational therapy, physical therapy, etc.) at school that would typically be provided pursuant to an Individualized Education Program (IEP) or Section 504 of the Rehabilitation Act of 1973 (Section 504) Plan—as opposed to crisis-related counseling from a psychologist, psychiatrist, or social worker-generally will be denied.

*This form does not apply to the following:

  • Therapists and other service providers who are providing in-school services in accordance with an agreement with MCPS, such as those service providers providing supports in accordance with a student’s IEP.
  • Private therapists or providers who are conducting observations or evaluations for special education eligibility or under an approved Independent Education Evaluation (IEE).
  • Outside service providers authorized by court order and/or by the Montgomery County Department of Health and Human Services, Child Protective Services.
Adobe PDF Request for Private Therapeutic Services in School456 KEnglish
Adobe PDF Petición de Servicios Terapéuticos Privados en la Escuela444 KSpanish
Adobe PDF Demande de Services Thérapeutiques Privés à l'école461 KFrench
Adobe PDF Yêu Cầu cho Các Dịch Vụ Điều Trị Cá Nhân tại Trường57 KVietnamese
Adobe PDF 校內私人治療服務申請610 KChinese
Adobe PDF 학교 내 개인 치료 서비스를 위한 신청472 KKorean
Adobe PDF ትምህርት ቤት ውስጥ ለግል የቴራፒዩቲክ - ህክምና አገልግሎቶች ጥያቄ469 KAmharic

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