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: August 2021

This form is used by the Interim Instructional Services (IIS) Office to obtain a psychiatrist’s/psychologist’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 is required for continuation of service beyond 60 calendar days.

Adobe PDF Application for Interim Instructional Services, with Qualified Mental Health Condition ONLY101 KEnglish

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