Hiawatha Valley Education District’s (HVED’s) day treatment programs(DTPs)are education based day treatment programs that were developed through interagency cooperation for students living in HVED districts.Though there is a focus on meeting the mental health and educational needs of learners in grades K through 9,placementof other learners are considered as well, when appropriate. Education services are provided by Hiawatha Valley Education District and mental health services are contracted from Family and Children’s Center (FCC) for Rainbow and Mid-Level programs and from Hiawatha Valley Mental Health Center (HVMHC) for the Wabasha County program. All programs are open to any HVED district / school. Students receiving services in these programs are required to be receiving an individualized special education program (IEP) and must be diagnosed with an emotional disturbance(ED or SED)via DSM IV-TR criteria. Rules and laws governing the provision of mental health services apply, as well as special education rules and regulations.

To ensure a free and appropriate public education(FAPE) in the least restrictive environment (LRE) for students being considered for this change of placement, certain procedures must have occurred. It is expected that the IEP team will include the school psychologistand other appropriate mental health providers in the school in completing this prereferral process.

PROCEDURES:

  1. The student’s IEP team ensures that appropriate educational assessment has occurred (including a Functional Behavioral Assessment) so decisions made are data based.
  2. The IEP team ensures that appropriate interventions have been attempted at the district level for an appropriatelength of time.
  3. The IEP team ensures a continuum of services (incremental increase of supports)have been provided to ensure LRE.
  4. When the IEP team determines that a referral to a DTP is appropriate, they must first receive signed written consent from a parent/guardian to share information with an outside mental health agency.(“Authorization for Release of Information”)
  5. Once prereferral procedures have occurred, the IEP team is required to submit the completed “Day Treatment Referral Form” to the HVED Cluster Director of Special Education.

Amy Adams, HVED North ClusterJudi Vold, HVED Central ClusterJoan Buehrle, HVED South Cluster

HVED PO Box 7WAPS 903 Gilmore AveHVED 211 Main St, Box 335

Kellogg, MN 55945Winona, MN 55987Hokah, MN 55941

Phone: (507) 767-3339 X 23Phone: (507) 494-0841Phone: (507) 894-4525 X 102

Fax: (507) 767-3232Fax: (507) 494-0807Fax: (507) 894-4543

Email: Email: Email:

  1. The director reviews the referral information and assists the district with completion of the process, as needed.
  2. Once prereferral processes have been completed and accepted, the director will pass a copy of the “Authorization for Release of Information” and prereferral documentation to the DTP mental health provider.
  3. The DTP team will collect any additional information needed from the school district and family.
  4. The DTP team will work with the student’s family and the district to arrange a screening meeting for team consideration of placement in the Day Treatment Program. The screening meeting will include the required IEP team members, including the day treatment providers.
  5. Consideration will be made for emergency or crisis placement.

Referral Form for

(while completing electronically, delete options not chosen)

RAINBOW / WINONA MID-LEVEL / WABASHA COUNTY DAY TREATMENT PROGRAM

(complete form via computer entry, print, include administrative signature, and fax, mail, or scan and send via secure email)

Student’s Full Name:

Birth Date:

Grade:

Resident School District:

Serving School District:

Address:

Parent(s) Address (if different):

Phone Number(s) (provide as many options as possible, indicating home, cell, or work):

____ 1.The IEP team has included the support of district mental health providers, including the school psychologist.

____ 2.Parent(s) have been informed of this referral and provided written consent to share information with the mental health center: Family and Children’s Center or Hiawatha Valley Mental Health Center(“Authorization for Release of Information” is attached.)

____ 3.Parents are aware that private or public insurance may be billed.

____ 4.The student is in a special education program.

____ 5.Maladaptive behaviors have occurred in the school in multiple settings and either in the community or home or both.

____ 6.The IEP has a current FunctionalBehavioralAssessment(FBA)completed for thestudent with ensuing intervention progress recorded.

Last two school service settings(classroom, resource room, one to one, homebound, separate site, residential, etc.):

Setting:Hours/day in setting:# of weeks or months in this setting:

Setting:Hours/day in setting:# of weeks or months in this setting:

Returning from a residential placement?(Yes /No)

1)Description of behaviors prompting referral and conditions known to prompt these behaviors; those behaviors seen or heard. (A current FBA may be attached in lieu of providing a written response.)

2)Frequency of behavior, e.g., times observed per month, week, or day. Include settings of most and least observed. Settings that may be included are classroom, resource room, home, playground, lunchroom, one to one, etc.

3)Interventions attempted. Describe most successful and least successful. (e.g. reward systems, behavior checklists, additional adult support, “think time”, detention, etc.

4)Conditional Procedures. If conditional procedures have been used(manual or mechanical or locked restraints, time out for seclusion, or temporary delay of regularly scheduled meals or water), summarize the use of these procedures (frequency, length of time, student response to use, etc.). If none used, record “NONE”.

5)History of all known school and mental health services, placements, and medications taken.

6)Diagnosis. Any current or recent diagnosis identified, if any.

Building Principal ______Date ______

Director of Special Education ______Date ______

Page 1 of 2