Client Name:______
H&CS ID#______
CHESTER COUNTY INTERMEDIATE UNIT
HOME & COMMUNITY SERVICES
LETTER OF ASSURANCE BETWEEN BEHAVIORAL HEALTH REHABILITATIVE
SERVICES (BHRS) PROVIDER AND EDUCATIONAL OR COMMUNITY SETTING
This Letter of Assurance, on ______, between ______
(Date) (School/Facility/Camp)
and CCIU/H&CS agrees to the following procedures for ______
(client, H&CS ID#)
in ______’s class/group at ______
(Teacher’s/Counselor’s Name) (Building/Facility)
Requirements for Meeting
The meeting to discuss Guidelines for Provision of BHRS in Educational and Community Settings must be held within the first two weeks at the beginning of a school year, or prior to the placement of a new TSS/BHPCA if the school or camp year is already underway. The new PCA/TSS must be included in this meeting.
Meeting Requirements Check List:
Form completed by Behavioral Health providerIndicate contact info for all team members (BHRS and School/Camp)
Review contingency plan (substitute requests)
Review treatment plan goals and interventions (responsibilities, etc).
Review TSS Schedule
Review TSS roles and responsibilities
Provide a copy of the school treatment plan (and get signatures if needed)
Discuss and coordinate the crisis plan (school’s plan and BHRS’ plan)
Obtain signatures of all present
Allow the School the opportunity to make a copy of this document
**The BHRS provider does not share the psychological evaluation report unless given permission by the parents/guardians.
Guidelines for Provision of Wraparound Behavioral Health Services (BHRS) in Educational or Community Settings
Form to be completed by Behavioral Health provider, signed by teacher, principal, counselor, and/or designee. Leave copy with school/facility.
Client’s Name:______
School/Community Setting:______
Date of Meeting:______
Name (print) Signature Position Organization____
*BSC/MT CCIU/H&CS
*TSS/BHPCA CCIU/H&CS
*Teacher/Counselor
Administrator
CM CCIU/H&CS
Parent
______Other Agency______
*Required Attendance at Meeting
The client currently attends:
Designate all that apply
School SettingRegular Education or Private Preschool Program
Autism Support
Academic Support
Resource Room
Emotional Support
Approved Private School
IU classroom or program
Early Intervention Program
IEP or 504 Plan
ESY
Integrated Classes
(typical and special education students)
Designate all that apply
Camps and Community SettingsTypical Day Camp Full-day
Typical Day Camp part-time or preschool camp
Specialized Activity Camp
Day Care
Specialized Class: Gymnastics, Art, Music, Drama, Computer, Swimming, Film, social skill group, etc.
Exercise Facility e.g. YMCA
Vocational (job or volunteer)
Library
Sports team
Community Activities, e.g. shopping, errands, public transportation (can be part of school or camp program)
Integrated activity, job, or camp
(typical and special needs children/teens/young adults)
Where can the TSS park?:______
Where is the sign-in book located?:______
What is the school’s dress code?:______
1. BHRS Contact Information:
Name / Position / Phone # / E-mail / Frequency of visits2. School Contact Information:
Name / Position / Phone # / E-mail3. TSS and school staff will collect data in order for the BSC to monitor the client’s progress. Indicate how data will be reported and shared to the team members.
______
4. Discuss the goals and interventions outlined in the treatment plan. Determine the hierarchy of implementing interventions (i.e. Does the teacher want to intervene first, or should the TSS.) (This would address behaviors after the teacher has given the initial instruction)
______
5. What is the plan of action in the event of a crisis situation? (attach crisis plan)
___Follow school protocol, refer to treatment plan for de-escalation/crisis intervention plan.
______
6. Determine what the contingency plan will be when the TSS/BHPCA is absent. Indicate how the client will be supported in school/camp/community program when the TSS/BHPCA is absent or unavailable and CCIU is unable to find a substitute.
Contingency PlanSchool will provide substitute aide
Camp will provide substitute aide
Client is able to share aide support with other students
Client is able to function without TSS for the day
Client cannot attend school/program that day if there is no TSS or substitute TSS.**
**applicable ONLY for privately paid preschools, camps, classes, and activity programs
7. Determine who will notify the school/facility/program if the TSS/BHPCA will be absent. Describe how appropriate personnel at the school or program will be notified.
Notification of TSS/BHPCA Absence(check all that apply)
TSS/BHPCA will telephone school
Tel. #: Email:
TSS/BHPCA will notify Case Manager
Tel. #: Email:
TSS will telephone family or caregiver*
Tel. #
The TSS/BHPCA will telephone BSC (or MT)**
Name:
Tel. #: Email:
**If the staff is very ill and/or unable to make more than one call, and it is before or after business hours, the staff or a designated person should telephone the BSC (MT if clinical lead). The BSC can then make the other necessary calls.
Weekly TSS/BHPCA Schedule
Client:______CCIU/H&CS Staff:______
SCHOOL OR PROGRAM: ______
CASE MANAGER:______Tel:______
E-mail: ______
BSC/MT NAME: ______Tel:______
E-mail: ______
DAY / Arrival Time / Lunch Time / Departure Time / Special CircumstancesMonday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TSS Responsibilities
While providing services in the school (or camp) setting, the TSS will:
1. Support the student in the environment to follow the daily schedule and participate in the educational program and activities.
2. Direct the student’s attention to classroom staff or activity when necessary.
3. Assist the classroom staff to ensure the safety of the student.
4. Assist the classroom staff to implement behavioral interventions for the student as developed and agreed upon by the behavioral support team (in coordination with the behavioral plan of the student’s IEP, when applicable).
5. Promote the student’s positive behavior and positive peer relationships.
6. Assist in the transfer of skills to the classroom staff in regards to behavior management. The main objective is to integrate the student into the classroom and eliminate the need for behavioral support.
7. Take data and report this data to the BSC to determine effectiveness of the treatment plan. The BSC will communicate the data analysis to the team as determined in the In-School Protocol Meeting.
8. Establish and maintain a respectful and professional relationship with personnel.
9. Observe rules and policies that govern staff behavior in the classroom.
10. Maintain the least intrusive role in the classroom. When not directly working with the identified student, the TSS will quietly observe and monitor the student.
11. Maintain the confidentiality of the identified student and all other students in the classroom (in compliance with FERPA and HIPAA).
Keep in mind that the TSS will not:
1. Serve as a replacement for the classroom staff (including supervision of the child’s toileting routine and administering medication or medical care).
2. Teach academics or pre-academic skills or content.
3. Provide support and/or interventions to any other student in the classroom.
4. Perform activities or duties that do not involve the identified student.
5. Socialize with the educational staff during instructional classroom hours.
6. Be alone with the identified student (or any student) at any time.
Procedures for TSS to follow while in the school.
1. Wear your agency ID at all times while working with your student.
2. Sign in & out of the classroom (school) log each time you enter and leave the building.
3. Follow building and classroom rules in place for all staff.
4. Use school telephones only in the case of an emergency. Cell phones are permitted in the buildings (unless otherwise specified by the school), but must be turned off during the school day. You may use your cell phone while on breaks, outside of the classroom or in the parking lot. In the event that your assigned child is having a difficult day, calls to the parent should be made only after other school procedures have been exhausted and you have been instructed to do so by school personnel.
5. No child should leave the school before the teacher has dismissed the class unless prior arrangements have been made. The TSS does not have the authority to take the student out of the building.
6. Agency staff will follow the building dress code.
7. The TSS will notify the classroom teacher of any absence or schedule change.
8. If you have any questions/concerns, speak to your case manager to solve the problem in an efficient and professional manner.
Suggestions for School Staff Working with TSS/BHPCA in School Setting
1. Establish a positive work environment for them:
a. Provide a work area or are where they can observe from
b. Provide an area for their personal belongings
c. Discuss classroom procedures that they will follow while in the classroom
d. Provide them with a school calendar
2. Introduce them to key staff members
a. Yourself
b. Educational assistants
c. Therapists
d. Other teachers and building staff with whom they may come in contact
e. Bus driver
3. Provide a ‘tour’ of the building
a. Adult and student restrooms
b. Lunch/break areas
c. Parking lots
d. Fire exits
e. Refrigerator/microwave they may use
4. Establish times for teacher/agency staff communication
a. Short segments of time between classes
b. Longer segments when needed
School/Camp representative, Director, Principal, or designee, BSC and TSS have reviewed and understand the policies and procedures of both the CCIU and the school. By signing below, you acknowledge that you are in agreement with the information discussed at this meeting:
______
School or Facility Administrator/Designee Date
______
Behavior Specialist or Case Manager Date
(professional title and credentials)
______
TSS/BHPCA Date
(professional title and credentials)
Submit original to CCIU/ H&CS
Leave copy with school or facility
Copies to TSS/BHPCA and BSC
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