Homebound Parent Referral Form

Does the student currently receive special education services?
Doctor's Contact Information
I certify the information above is correct and authorize the release of any medical or psychological information necessary to process this referral including current treatment plans and the projected length of time out of school due to the medical condition.
I understand an adult 18 years of age or older, must be present in the home for the duration of the homebound teacher’s visitation. This individual will be required to sign the Instructional Delivery log documenting the date and time of the visit.
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