FormsParents & StudentsInterim Instructional Services → Application for Interim Instructional Services, with Qualified Mental Health Condition ONLY

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

About this Form

Form number: 311-15C

Audience:  Parents/Guardians, School Staff

Last revised: July 2023

Note: This form is used by the Interim Instructional Services (IIS) Office to obtain a psychiatrist’s, psychologist’s, or certified mental health nurse practitioner’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. For more information, see MCPS Regulation IOE-RB, Interim Instructional Services.
A new completed application, with updated information from the practitioner regarding diagnosis and treatment is required for continuation of service beyond 60 calendar days.
In order for this application to be considered, ALL components of this application must be completed and submitted:
I. Parent portion including signature
II. School portion
III. Practitioner verification including specific steps the school can take to support the student returning to instruction
IV. Return to school plan: The conversation regarding the return to school plan should happen with all stakeholders prior to the submission of the application. It is preferable that the plan be submitted with the application, but it must be submitted no later than 30 days after the application submission.

The school must send the form electronically, when completed, to Delivery of IIS will be virtual. Individual exceptions will require review and approval by the Supervisor of Interim Instructional Services. 


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