FormsParents & StudentsHome and Hospital Teaching → 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: August 2024


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 IISOffice@mcpsmd.org. Delivery of IIS will be virtual. Individual exceptions will require review and approval by the Supervisor of Interim Instructional Services. 

 

Adobe PDF Application for Interim Instructional Services, with Qualified Mental Health Condition ONLY110 KEnglish
Adobe PDF Solicitud para Servicios Instructivos Provisionales, SOLO con Condición de Salud Mental Calificada72 KSpanish
Adobe PDF Demande de services d'enseignement provisoires, pour individus à état de santé mentale éligible UNIQUEMENT71 KFrench
Adobe PDF Đơn cho Các Dịch Vụ Giảng Dạy Tạm Thời, CHỈ với Điều Kiện Sức Khỏe Tinh Thần226 KVietnamese
Adobe PDF 臨時教學服務申請(僅限符合條件的心理健康狀況)208 KChinese
Adobe PDF 임시 교습 서비스 지원서(승인된 정신 건강 상태인 학생용)142 KKorean
Adobe PDF ለጊዜያዊ የትምህርት አገልግሎት ማመልከቻ፣ መስፈርት ለሚያሟላ የአእምሮ ጤና ሁኔታ ብቻ89 KAmharic
Adobe PDF Pedido de Serviços Instrucionais Provisórios, SOMENTE com Condição de Saúde Mental Qualificada71 KPortuguese

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat