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Referral Procedures

Students with Physical Conditions

Students recovering from temporary medical conditions—such as surgery, broken bones, mononucleosis, and accident injuries—are expected to be homebound or hospitalized for at least 20 or more consecutive school days may be eligible for services.  Appropriate forms are completed and submitted to the Office of Home and Hospital Teaching.  If the student is eligible for services, the Office of Home and Hospital Teaching assigns a home teacher who will contact the school to arrange an initial conference to pick up books and assignments and to discuss grading procedures in addition to other pertinent matters.  Instructional services are provided in the home, hospital, or therapeutic center.  The Physician’s Verification form (DSS-22) must be updated if the student has not recovered from the temporary health condition within the time frame indicated by the physician, not to exceed sixty (60) calendar days.

      a.     Parent and professional school counselor complete the Initial Contact and Referral form (DSS-21);

      b.     Licensed physician completes and signs the Physician's Verification form (DSS-22), which is returned to the Principal/Designee;

      c.     Principal/Designee emails copies of the DSS-21 and DSS-22 to the following email: home.hospital@pgcps.org;

      d.     The Office of Health Services reviews the physician's form and assists in determining eligibility;

      e.     The Office of Home and Hospital Teaching assigns a home teacher;

      f.     The Principal/Designee conducts a conference and attendees complete the Service Agreement;

      g.     Student returns to school or obtains reverification of medical need.


Students Who Are Pregnant

Students attend school until confinement per the licensed physician’s recommendation.  Students typically receive services up to six weeks postpartum.  The pregnant student and her parent meet with the professional school counselor to complete the referral paperwork which is forwarded to home.hospital@pgcps.org so a home teacher can be assigned.  The home teacher will contact the school to arrange an initial conference to pick up books and assignments and to discuss grading procedures in addition to other pertinent matters.

a.   Parent and professional school counselor/principal’s designee complete the Initial Contact  and Referral form (DSS-21);

b.  Licensed physician completes and signs the Physician’s Verification form (DSS-22), which is returned to the Principal/Designee;

c.  Principal/Designee emails copies of the DSS-21 and DSS-22 to the following email: home.hospital@pgcps.org;

d.  Office of Home and Hospital Teaching assigns a home teacher;

 e.  Principal/Designee conducts a conference and attendees develop the Home and Hospital Teaching Service Agreement;

 f.  Student returns to school at the conclusion of home teaching eligibility.


Students with Emotional Conditions

Students may be experiencing emotional conditions that require treatment.  A licensed psychologist or psychiatrist must complete and sign the Psychologist’s or Psychiatrist's Verification: Emotional Conditions form (DSS-22A) including the treatment plan.  The school psychologist reviews and signs/initials the Psychologist's or Psychiatrist's Verification form and Transition Plan if approved.  The student continues therapy or counseling sessions and transitions back into the school program within sixty (60) calendar days. 


a.  Parent and principal/designee complete Initial Contact and Referral form (DSS-21);

b.  Licensed psychologist/psychiatrist completes and signs the Psychologist's or Psychiatrist's Verification form (DSS-22A), which is returned to the Principal/Designee;

c.  Principal/Designee forwards the Physician's Verification form (DSS-22A) to the school team. The school team meets and completes the Transition Plan. The School Psychologist reviews and initials the form;

d.  Principal/Designee forwards a copy of the Initial Contact and Referral form, the Psychologist's or Psychiatrist's Verification form and the Transition form, initialed by the school psychologist, to home.hospital@pgcps.org;

e. The Office and Home and Hospital Teaching reviews the packet and forwards it to The Office of Psychological Services for final review and  approval;

d.  If approved, the Office of Home and Hospital Teaching assigns an instructional teacher;

e.  Principal/Designee conducts a conference and attendees develop a Service Agreement, to include location of instruction, transition timeline for reintegration into school program, and date/time for the 30-day review conference;

f.  Team conducts 30-day conference to review student progress toward successful re-entry into school.


Students with Concurrent Health Conditions

Students having concurrent, long-term medical conditions—such as sickle cell anemia or cystic fibrosis—which affect a student's ability to attend school classes for intermittent periods of time due to illness.  They attend school daily, as much as their health permits.  The school monitors the student monthly via a school team meeting (SIT, SST, IEP, 504).

a.  Parent and principal/designee complete the Initial Contact and Referral (DSS-21);

b.  Licensed physician completes and signs the Physician’s Verification form (DSS-22), which is returned to the Principal/Designee;

c.  Principal/Designee emails the Initial Contact and Referral form and the Physician's Verification form to home.hospital@pgcps.org;

d.  Office of Home and Hospital Teaching assigns an instructional teacher;

e.  Principal/Designee convenes an appropriate conference:

The 504 Conference:

  • Principal/Designee conducts a 504 conference per the 504 procedures and forwards a copy of the 504 to the Office of Home and Hospital Teaching;
  • The team develops the Home and Hospital Service Agreement.

The IEP Conference:

  • Principal/Designee conducts an IEP meeting per special education procedures and forwards a copy of the Prior Written Notice to the Office of Home and Hospital Teaching;
  • The team amends the IEP as appropriate.