Forms

Forms Boundary School Administrator needs completed to begin Short/Long-Term H&H process:

H&H Flowchart

Dr.'s Statement of Needs
Physician, Psychologist, or Licensed Clinical Social Worker verification stating the reason(s) for H&H services and the length of time recommended.

Registration Form
Parent/guardian and boundary school administrator completes the H&H Registration Form.

Short-Term Disclosure Statement
Facilitates understanding of the short-term H&H program.

Long-Term Disclosure Statement
Facilitates understanding of short/long-term H&H program.


Teacher Forms:

Mileage Report
District Mileage Report to be submitted monthly for each student on the program – be sure to list the address of the student served with the student’s name.

Monthly Teaching Record  
Teacher records weekly visits to students including time with student, mileage, and any comments.

Time Sheet
District timesheet to be submitted monthly – be sure to correspond the name of the student served with time charged.