Montgomery County Public Schools

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

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.

Application for Interim Instructional Services, with Qualified Mental Health Condition ONLY	101 K	English
Solicitud para Servicios Instructivos Provisionales, SOLO con Condición de Salud Mental Calificada	66 K	Spanish
Demande de services d'enseignement provisoires, pour individus à état de santé mentale éligible UNIQUEMENT	67 K	French
Đơn cho Các Dịch Vụ Giảng Dạy Tạm Thời, CHỈ với Điều Kiện Sức Khỏe Tinh Thần	141 K	Vietnamese
臨時教學服務申請(僅限符合條件的心理健康狀況)	168 K	Chinese
임시 교습 서비스 지원서(승인된 정신 건강 상태인 학생용)	116 K	Korean
ለጊዜያዊ የትምህርት አገልግሎት ማመልከቻ፣ መስፈርት ለሚያሟላ የአእምሮ ጤና ሁኔታ ብቻ	106 K	Amharic
Pedido de Serviços Instrucionais Provisórios, SOMENTE com Condição de Saúde Mental Qualificada	64 K	Portuguese

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