Hiawatha Valley Education District (HVED)
Prereferral Process for
Rainbow Day Treatment Program (at Jefferson Elementary in Winona, MN) for students grades K-4
Winona Mid-Level Day Treatment Program (223 Center Street, Winona, MN) for students grades 5-8
Wabasha County Day Treatment Program (at River Valley Academy in Kellogg, MN) for students grades 7-12
(All programs are available for referral from any HVED school / district.)
Hiawatha Valley Education District’s (HVED’s) day treatment programs (DTPs) are education based day treatment programs that were
developed through interagency cooperation for students living in HVED districts. Though there is a focus on meeting the mental health
and educational needs of learners in grades K through 9, placement of other learners are considered as well, when appropriate.
Education services are provided by Hiawatha Valley Education District and mental health services are contracted from Family and
Children’s Center (FCC) for Rainbow and Mid-Level programs and from Hiawatha Valley Mental Health Center (HVMHC) for the
Wabasha County program. All programs are open to any HVED district / school. Students receiving services in these programs are
required to be receiving an individualized special education program (IEP) and must be diagnosed with an emotional disturbance (ED
or SED) via DSM IV-TR criteria. Rules and laws governing the provision of mental health services apply, as well as special education
rules and regulations.
To ensure a free and appropriate public education (FAPE) in the least restrictive environment (LRE) for students being considered for
this change of placement, certain procedures must have occurred. It is expected that the IEP team will include the school psychologist
and other appropriate mental health providers in the school in completing this prereferral process.
PROCEDURES:
1. The student’s IEP team ensures that appropriate educational assessment has occurred (including a Functional
Behavioral Assessment) so decisions made are data based.
2. The IEP team ensures that appropriate interventions have been attempted at the district level for an appropriate
length of time.
3. The IEP team ensures a continuum of services (incremental increase of supports) have been provided to ensure LRE.
4. When the IEP team determines that a referral to a DTP is appropriate, they must first receive signed written consent
from a parent/guardian to share information with an outside mental health agency. (“Authorization for Release of
Information”)
5. Once prereferral procedures have occurred, the IEP team is required to submit the completed “Day Treatment
Referral Form” to the HVED Cluster Director of Special Education.
Amy Adams, HVED North Cluster
HVED PO Box 7
Kellogg, MN 55945
Phone: (507) 767-3339 X 23
Fax: (507) 767-3232
Email: aadams@hved.org
Judi Vold, HVED Central Cluster
WAPS 903 Gilmore Ave
Winona, MN 55987
Phone: (507) 494-0841
Fax: (507) 494-0807
Email: jvold@hved.org
Joan Buehrle, HVED South Cluster
HVED 211 Main St, Box 335
Hokah, MN 55941
Phone: (507) 894-4525 X 102
Fax: (507) 894-4543
Email: jbuehrle@hved.org
6. The director reviews the referral information and assists the district with completion of the process, as needed.
7. Once prereferral processes have been completed and accepted, the director will pass a copy of the “Authorization
for Release of Information” and prereferral documentation to the DTP mental health provider.
8. The DTP team will collect any additional information needed from the school district and family.
9. The DTP team will work with the student’s family and the district to arrange a screening meeting for team
consideration of placement in the Day Treatment Program. The screening meeting will include the required IEP team
members, including the day treatment providers.
10. Consideration will be made for emergency or crisis placement.
Created July 23, 2010; Updated 11/1/10
Referral Form for
(while completing electronically, delete options not chosen)
RAINBOW / WINONA MID-LEVEL / WABASHA COUNTY
DAY TREATMENT PROGRAM
(complete form via computer entry, print, include administrative signature, and fax, mail, or scan and send via secure email)
Student’s Full Name:
Birth Date:
Grade:
Resident School District:
Serving School District:
Address:
Parent(s) Address (if different):
Phone Number(s) (provide as many options as possible, indicating home, cell, or work):
Prereferral Checklist
____ 1. The IEP team has included the support of district mental health providers, including the school psychologist.
____ 2. Parent(s) have been informed of this referral and provided written consent to share information with the mental health center:
Family and Children’s Center or Hiawatha Valley Mental Health Center (“Authorization for Release of Information” is attached.)
____ 3. Parents are aware that private or public insurance may be billed.
____ 4. The student is in a special education program.
____ 5. Maladaptive behaviors have occurred in the school in multiple settings and either in the community or home or both.
____ 6. The IEP has a current Functional Behavioral Assessment (FBA) completed for the student with ensuing intervention progress
recorded.
Description of behavior, frequency of problem behaviors, services, and prereferral interventions
Last two school service settings (classroom, resource room, one to one, homebound, separate site, residential, etc.):
Setting:
Hours/day in setting:
# of weeks or months in this setting:
Setting:
Hours/day in setting:
# of weeks or months in this setting:
Returning from a residential placement? (Yes /No)
1) Description of behaviors prompting referral and conditions known to prompt these behaviors; those behaviors seen or heard. (A
current FBA may be attached in lieu of providing a written response.)
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2) Frequency of behavior, e.g., times observed per month, week, or day. Include settings of most and least observed. Settings that
may be included are classroom, resource room, home, playground, lunchroom, one to one, etc.
3) Interventions attempted. Describe most successful and least successful. (e.g. reward systems, behavior checklists, additional
adult support, “think time”, detention, etc.
4) Conditional Procedures. If conditional procedures have been used (manual or mechanical or locked restraints, time out for
seclusion, or temporary delay of regularly scheduled meals or water), summarize the use of these procedures (frequency, length
of time, student response to use, etc.). If none used, record “NONE”.
5) History of all known school and mental health services, placements, and medications taken.
6) Diagnosis. Any current or recent diagnosis identified, if any.
Signatures
Building Principal _____________________________________________________________ Date ____________________
Director of Special Education ____________________________________________________ Date ____________________
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