Division of Student Health and Human Services

Division of Student Health and Human Services

LOS ANGELES UNIFIED SCHOOL DISTRICT

Division of Student Health and Human Services

SCHOOL SITE SERVICE DELIVERY PLAN

PLEASE COMPLETE ONE INFORMATION FORM FOR EACH SCHOOL SITE WHERE SERVICES WILL BE DELIVERED.

Name of Agency:
Agency Executive: Director / Title:
Business Address: / Telephone:
Fax: ______
Agency Contact: / Title:
School: / District: / DIST ADIST BDIST CDIST DDIST EDIST FDIST GDIST HDIST IDIST JDIST JDIST K / Complex: / SPA: / SPA 2SPA 3SPA 4SPA 5SPA 6SPA 7SPA 8
School Contact: / Title: / Telephone:
Dates of Service / From: / To: / Hours: / Days:
Describe the referral process at your school:
Describe the room or space availability on the school site for services:

Identify the District’s on-site staff member with an appropriate Credential that will liaison with agency personnel (Mental Health Service Providers must establish a liaison with a Pupil Personnel Service Credential holder):

Name: / Title: / Credential:

Supervision of Agency Interns, Residents, and Staff: The supervision of staff from an agency is the responsibility of the agency. A plan for staff supervision should be provided detailing the frequency and location of supervision and the certification or licensure of the supervisor. The malpractice and general liability insurance of the agency must cover any work done by the interns or residents brought to the school by the agency.

Describe the staffing and SUPERVISION PLAN for interns, residents or trainees (supervisor’s name, qualifications, schedule and location of supervision sessions):
List agency staff assigned to this school site (check all that apply)
NAME / LIC. TYPE / LIC. NO. / EXP. DATE / TB DATE / INTERN / CLERICAL / SUPERVISOR / OTHER

Please list the names and titles of the individuals who participated in the development of this School Site Service Delivery Plan.

NAME / TITLE
Describe the sign-in procedures and
the provision for identification badges:
List agency needs from the
school, including personnel:
Language(s) spoken by agency personnel on site:
MENTAL HEALTH
(Check all that apply and describe in detail.)
Individual Child Therapy / Case Management / Clerical & Translation
Family Therapy / Training / Education Classes
Group Therapy / Interns / Parenting Classes
Consultation / Medi-Cal Enrollment / Other: ______
Information & Referrals / Substance Abuse Prevention
Medi-Cal Provider: YN / DMH PROVIDER NUMBER:
Describe the type and extent of services, follow-up, and evaluation procedures:
Department of Mental Health SECTOR CHIEF (if applicable) :
HEALTH SERVICES
(Check all that apply and describe in detail.)
Immunizations / Reproductive Health Services
Physical Exams / Mantoux Testing
Dental Screening Dental Sealant / Substance Abuse
Fluoride Treatment Dental Treatment / Clerical & Translation
Vision Screening Refraction / Pharmacy
Dispensing of Glasses / Other: ______
Medical Diagnosis & Treatment Services / Medi-Cal Provider: Y N
Describe the type and extent of services and follow-up planned:

GUIDELINES FOR INDIVIDUAL/AGENCY PROVIDING VOLUNTEER MENTAL AND/OR HEALTH SERVICES TO LAUSD

All individuals or agencies that provide volunteer mental or health services to students of the Los Angeles Unified School District must agree to:

  1. Receive assistance from a LAUSD health and human services staff member holding a valid credential.
  1. Consult with the assigned health and human services staff member on a regular basis when a problem arises that needs immediate attention.
  1. Understand and comply with District policy regarding liability and professional malpractice coverage.
  1. Become knowledgeable regarding the law and District policies concerning confidentiality, child abuse, and students who may pose a threat to self or others. Policy bulletins on these subjects are available upon request.
  1. Maintain appropriate confidentiality regarding health and mental health services.
  1. Complete the commitment of volunteer services in terms of the number of days and time, and be regular and punctual in attendance.
  1. Provide for the cost and care of equipment to be used, and to complete LAUSD approved inventory-reporting forms.
  1. Make certain that a signed consent for each student is on file before health or mental health services are provided. The school will notify parent(s)/guardian(s) of services available.
  1. Report any questionable or abnormal findings to the parent(s)/guardian(s) on LAUSD approved notification forms. Translation into languages other than English may be required.
  1. Notify assigned District health services staff of questionable or abnormal findings and recommendation of referrals.
  1. Charge no fee for service and use no written or verbal solicitation for self-referral; use no information learned about LAUSD student(s) for personal gain or profit.
  1. Refer only to community agencies having non-profit status and make no referrals to a designated individual or class of practitioner.
  1. Include Disclaimer Statement with Informed Consent of Parents/Guardians: When parent(s)/guardian(s) are informed about the availability of services at the school site, it must be made clear that the agency’s services are not a part of the regular and ongoing programs of the school or LAUSD. The community service is being made available to students and their families as a convenience, bringing agency personnel to the campus where the parents can have greater access to services. A signed “informed consent” of the parent, which includes this information, must be obtained by the agency prior to any assessment, evaluation or intervention.
  1. Fee Disclosure (for LA County Department of Mental Health and its sub contractors only): The agency/worker must disclose any fees or co-payments that the parent may be asked to pay. For referral to the agency’s off-site services, providers are required to inform parents that they accept Medi-Cal, private insurance, or assess a fee based on a sliding scale of income. The Universal Method for Determining Ability to Pay (UMDAP) process and required information, e.g. paycheck stubs, utility bills, and other required documents should be disclosed as part of the initial service planning with schools. LAUSD does not assume responsibility for payment of any fees or costs related to an agency referral. While a child may “benefit” from services offered by an agency or program, no one can require parents to accept services. At this time, services cannot be required as a condition of school attendance. Referrals of students to an agency should be a part a continuum of services available to students. Professional treatment does not take the place of prevention, early intervention, support, educational counseling, DIS counseling, and discipline at the school.
  1. Ensure That All Students Will Have Access To On-Site Care, Regardless Of Their Ability To Pay: An agency at a school site cannot provide treatment to Medi-Cal/Healthy Families clients only. All agencies must understand it is incumbent on them to help all children who want and need treatment, not only those that have insurance or can afford to pay.

Many healthcare access options now exist for medically indigent children. It is expected that all providers will promote and support family enrollment in available programs including Medi-Cal and Healthy Families.

  1. Establish good Communication Between Agency And School Staff: An initial two way release of information form may be signed at the same time that the parent consents for services. This permits the school and the providers to share appropriate information that can assist in the child’s progress socially, emotionally, behaviorally and academically. Regular meetings between the agency and school staff should be held for feedback on the referral process and to address any issues or concerns in a timely fashion.
  1. Assist in School Documentation: A notation of the referral date and agency on the student’s health card or cumulative record is important. The provider should inform the nurse at the school to incorporate this information on the health card. The provider should also inform the psychologist, psychiatric social worker, counselor or any other Student Health and Human Services staff person about the referral in order to coordinate any current or future student interventions. This information may serve as crucial historical documentation of support services provided to the student in the event that special education services or other serious actions such as suspension or expulsion become necessary.
  1. Plan Mandated Reporting Procedures: Sensitive information is often uncovered in the course of counseling. It is important for the principal and agency staff to collaborate in advance on how the agency will handle sensitive information which affects the student such as physical or sexual abuse allegations, child neglect, drug/alcohol abuse, criminal activity in the home, etc.

Please attach proposed consent forms to be completed by parent(s))/guardian(s) of student(s) who will participate in the services offered.

I have read and understand these Guidelines and agree to comply with all of the LAUSD requirements. Failure to comply with these guidelines may result in termination of services.

1) AGENCY NAME:

 SIGNATURE ______DATE______

Authorized Agency Representative

2) SCHOOL NAME:

 SIGNATURE______DATE______

School Principal

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