Request for Private Therapeutic Services in School

INSTRUCTIONS: The parent/guardian is to complete the entire form and submit to the principal/designee of the student’s home school. A new request must be submitted each school year.
This request form is used by the school principal/designee to determine whether or not to approve requests from parents/guardians for a private therapist to work with a student at school during the school day. Each provider must be approved to work with a student; and there are no therapists or agencies that have been pre-approved to provide such private therapy services to multiple students*. It is the sole discretion of the principal/designee to approve or deny any request for school visitors in accordance with MCPS Regulation ABA-RB, School Visitors. Parent/guardian requests for private therapists to provide Applied Behavior Analysis (ABA) therapy and other related services (such as speech, occupational therapy, physical therapy, etc.) at school that would typically be provided pursuant to an Individualized Education Program (IEP) or Section 504 of the Rehabilitation Act of 1973 (Section 504) Plan—as opposed to crisis-related counseling from a psychologist, psychiatrist, or social worker-generally will be denied.

*This form does not apply to the following:

• Therapists and other service providers who are providing in-school services in accordance with an agreement with MCPS, such as those service providers providing supports in accordance with a student’s IEP.
• Private therapists or providers who are conducting observations or evaluations for special education eligibility or under an approved Independent Education Evaluation (IEE).
• Outside service providers authorized by court order and/or by the Montgomery County Department of Health and Human Services, Child Protective Services.

Request for Private Therapeutic Services in School	456 K	English
Petición de Servicios Terapéuticos Privados en la Escuela	444 K	Spanish
Demande de Services Thérapeutiques Privés à l'école	461 K	French
Yêu Cầu cho Các Dịch Vụ Điều Trị Cá Nhân tại Trường	57 K	Vietnamese
校內私人治療服務申請	610 K	Chinese
학교 내 개인 치료 서비스를 위한 신청	472 K	Korean
ትምህርት ቤት ውስጥ ለግል የቴራፒዩቲክ - ህክምና አገልግሎቶች ጥያቄ	469 K	Amharic

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat