CESA #10
725 W PARK AVENUE
CHIPPEWA FALLS WI 54729
SPECIAL EDUCATION DEPT.
(715) 723-0341
SCHOOL DISTRICT SERVICES PLAN
Name of child
Date of Birth
Parent or legal guardian
Address
District of residence
Telephone No. (include area code)
Gender
Grade
Race/ethnic (if parent chooses to
identify)
Meeting Date: __________________________
Purpose of meeting: _____________________________________
 Initial Evaluation  Reevaluation  Initial or annual Services Plan development  Placement
 Services Plan Review/Revision  Develop a statement of transition goals and services (required for students age 14 and
older, or younger if appropriate)  Other_____________________________________
SERVICES PLAN MEETING PARTICIPANTS
Child (if appropriate)
LEA Representative/title
Regular education teacher/title
Other/title
Special education teacher/title
Other/title
Parent/guardian
Other/title
Parent/guardian
Other/title
Documentation of efforts to involve the parents in the Services Plan meeting:
1._____________________________
2.______________________________
3.______________________________
Your Child’s Services Plan
Special services are provided to your child through the cooperation of your child’s private school and the local public school
district. The following summarizes what you can expect of these special services, and how they are different from special
education.
All children who attend public school are entitled to a free appropriate public education, which includes special education. This
entitlement does not apply to students who attend a private school (including home school) at the parent’s choice.
The school district receives federal funds through the Individuals with Disabilities Education Improvement Act (IDEA). With
these funds, the school district must look for all children who are suspected of having a disability and provide them with an
individual assessment. Complaints about our child find process may be sent to the Director of Special Education at CESA
#10, 725 W Park Avenue, Chippewa Falls, WI, 54729, 715-720-2059.
A small share of IDEA funds must also be used to provide some services to children who attend private schools located within
the school district boundaries. Because of the small level of funding available, the full range of special education services is
not available to students attending private schools. It is up to the school district to decide on what services will be provided
with those funds. The school district consults annually with a private school representative on how best to use the funds
available for students attending private school.
Public school students receive special education services through an Individualized Education Program (IEP). Similar forms
and procedures are used to develop a plan for students from a private school, but the same legal rights do not apply. Instead
of an IEP, the written plan for private school students is called a Services Plan. Instead of a receiving a “Parent and Child
Rights” brochure, parents receive this description of “Your Child’s Services Plan.” Parents of students who have a Services
Plan do not have the right to file a complaint with the Wisconsin Department of Public Instruction regarding which services are
available, the contents of the services plan, or how the services are delivered. Complaints about the school district’s
compliance with the requirements for services to parentally-placed private school students, however, may be filed with the
Wisconsin Department of Public Instruction, 800-441-4563.
Questions regarding this Services Plan may be directed to the school psychologist at the school district providing these
services, or to the Director of Special Education at CESA #10, 725 W Park Avenue, Chippewa Falls, WI, 54729, 715-7202059.
Rev. 11/07
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SERVICES PLAN
Name of child: _____________________________________________
I.
Date of meeting: ___________________________
Consideration of Special Factors:
A. Does the child’s behavior impede his/her learning or that of others?
 Yes
 No
If yes, list positive behavioral interventions, supports, and other strategies to address that behavior:
B. Does the child have limited English proficiency?
 Yes
 No
 Yes
 No
 Yes
 No
If yes, describe the language needs that relate to this Services Plan:
C. Does the child have communication needs that could impede his or her learning?
If yes, describe:
D. Does the child need assistive technology services or devices?
If yes, specify characteristics of device(s) or service(s) considered:
II. Disability Related Special Factors:
A. Deaf or Hard of Hearing Child
Is the child deaf or hard of hearing?
 Yes  No
If yes, did you consider:
 the child’s language and communication needs
 opportunities for direct communications with peers and professional
personnel in the child’s language and communication mode
 necessary opportunities for direct instruction in the child’s language
and communication mode
Summarize Considerations:
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 Yes
 No
 Yes
 No
 Yes
 No
Page _________ of ________
B. Visually Impaired Child
If visually handicapped, does the child demonstrate a current need for Braille instruction? In making the
determination, consider reading/written media and future needs for Braille skills. See Summary Report of
Assessment Findings for justification.  Yes  No  N/A
If no, justify:
III. Other Factors/Considerations:
A.
Document consideration of District-wide assessments.
B. Transition: Complete Summary of Transition Services if child is age 14 or older, or will reach the age of 14 during
the timeframe of this Services Plan.
C. Testing Accommodations and Participation in Schoolwide Assessments:
D. Testing Accommodations in the Classroom.
List specific accommodations formally received and actually used by the student during classroom testing. All
accommodations should be directly related to functional limitations of the child's impairment.
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PRESENT LEVEL OF ACADEMIC ACHIEVEMENT AND FUNCTIONAL PERFORMANCE
Name of child: _____________________________________________
Date of meeting: ___________________________
IV. Present Level of Academic Achievement and Functional Performance:
Include a statement of how the child’s disability affects the child’s involvement and progress in the general curriculum (for
preschool children, how the disability affects participation in appropriate activities). Consider: (1) the strengths of the child,
(2) the concerns of the parents for enhancing the education of the child, (3) the results of the initial or most recent evaluation
of the child, and (4) the academic, developmental, and functional needs of the child.
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Page _________ of ________
SERVICES PLAN
MEASUREABLE ANNUAL GOALS
Name of child: _____________________________________________
Date of meeting: ___________________________
V. Measurable annual goal(s).
Measurable annual goal.
How will progress toward attaining the annual goal be measured.
How will the child’s parents be notified of the child's progress toward the annual goal. This must be done at least as often as
progress is reported for non-disabled children.
Measurable annual goal.
How will progress toward attaining the annual goal be measured.
How will the child’s parents be notified of the child's progress toward the annual goal. This must be done at least as often as
progress is reported for non-disabled children.
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SERVICES PLAN
Name of child: _____________________________________________
Date of meeting: ________________________
VI. Instructional Services:
Projected beginning and ending dates of services and modifications
_________________ to __________________
(Includes only scheduled school days, unless otherwise specified)
month/day/year
month/day/year
A statement for each of the following with amount, frequency, location, and duration:
Special education:
Amount/Frequency
Location
Duration
Supplemental aids & services:
a) Aids, services, and other supports provided to or on behalf of
the child in regular education or other educational settings by
regular education and/or special education staff.
 Yes  No If yes, describe:
Amount/Frequency
Location
Duration
Amount/Frequency
Location
Duration
b) Program modifications or supports for school personnel that
will be provided.
 Yes  No If yes, describe:
Related services:
 Yes (if yes, specify)
 No
 None needed to benefit from
special education
Explanation of need for services:
 Assistive Technology
 Audiology
 Counseling
 Educational interpreting
 Medical services for diagnosis & evaluation
 Occupational therapy
 Orientation & mobility (VI only)
 Physical therapy
 Psychological services
 Recreation
 Rehabilitation counseling services
 School nursing services
 Social work
 Speech and language
 Transportation
 Other, specify:
 Medication management per prescription
If specially designed, specify or reference goals & objectives:
Physical education  Regular
Vocational education  Regular
Rev. 11/07
 Specially designed  N/A
 Specially designed  N/A
Page _________ of ________
SERVICES PROGRAM
Name of child: _____________________________________________
Date of meeting: _______________________
VII. Determination of LRE (least restrictive environment):
A. Describe the extent, if any, to which the child will not participate in the regular educational environment. The regular
education environment is an instructional grouping with nondisabled peers (regular classroom or other setting). If the
child will not participate full time in the regular education environment, the extent of the removal from the regular
education environment must be determined and clearly stated.
B. Document the reasons for concluding that, even with supplemental aids and services, the nature and severity of the
child’s disability is such that education with nondisabled peers in the regular educational environment cannot be
satisfactorily achieved. Document consideration of the potential harmful effects on the child or the quality of services.
C. Describe the extent, if any, to which the child will not participate in the general curriculum. The general curriculum is
the common core of subjects or curriculum areas adopted by the school that applies to all children within each
general age grouping from preschool through secondary school. The Services Plan team must decide whether the
child will be expected to accomplish the same curriculum goals as the nondisabled students within the school. If the
child will not be expected to do so, the extent to which the child will not participate in the general curriculum must be
described.
D. Document the reasons for concluding that, even with supplemental aids and services, the nature and severity of the
child’s disability is such that participation in the general curriculum cannot be satisfactorily achieved.
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Page _________ of ________
VII. Determination and Notice of Placement
The Services Plan developed on ________________________ will be implemented at
_____________________________________________________________
(School)
Projected date of implementation: _________________.
(Date)
List other options considered, if any, (related to the frequency, location, and the duration of the special education and
related services, supplementary aids and services, program modifications and supports, and the place of those services).
List the reason(s) rejected, and the description of any other factors relevant to the purposed action:  None
You have previously received a statement of procedural safeguards. If you would like another copy of the procedural
safeguards available to you as the parent of a child with a disability or if you have questions about this information, please call
me.
__________________________________________________________
Name and Title of District Contact Person
________________________________
Telephone
Date that a copy of the plan, including Placement Notice was sent to parent/guardian:______________________
If you wish to contact someone other than the person indicated to discuss your rights, please refer to the parent and child
rights brochure for the names and telephone numbers of organizations you can contact, or call the Special Education
Department at CESA #10, (715) 723-0341.
Rev. 11/07
Page _________ of ________
SUMMARY OF TRANSITION SERVICES
Name of Student __________________________________
Postsecondary goals and needed transition services must be developed annually for all students who are
age 14 or will turn 14 during the timeframe of this Services Plan, or who are younger than age 14 and
need transition services.
List the date and method of inviting the student to Services Plan team meeting (if the student’s name was not
included on the invitation to the Services Plan meeting)
List the steps that were taken to ensure that the student’s preferences and interests are considered (if the student
is not at the Services Plan team meeting)
State measurable postsecondary goal(s) based upon age appropriate transition assessments related to
education, training, employment and where appropriate independent living skills.
(Note: for each measurable postsecondary goal(s) there must be at least one measurable annual goal included in the
Services Plan that will help the student make progress towards meeting the stated postsecondary goal(s)).
Education, Training, and Employment:
Where appropriate, Independent Living Skills:
Are the measurable postsecondary goal(s) based on age appropriate transition assessments and are those
assessments documented? □ Yes
□ No
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Page _________ of ________
Transition Services means a coordinated set of activities designed within a results-oriented process focused on
improving the academic and functional achievement of the child with a disability to facilitate the child’s movement
from school to post-school activities, including post-secondary education, vocational education, integrated
employment (including supported employment), continuing and adult education, adult services, independent
living, or community participation and is based on the student’s needs, taking into account the student’s
strengths, preferences and interests.
Describe the transition services needed to assist the student in reaching the above goals, (Transition services
include but are not limited to instruction, related services, community experience, integrated employment including supported
employment, development of employment and other post-school adult living objectives, functional vocational evaluations and
if appropriate, the acquisition of daily living skills.)
(If the transition services are contained elsewhere in this Services Plan, you may provide a cross reference.)
Will other agencies likely be involved in providing or paying for any transition services?
□ Yes
□ No
If yes, describe the services:
If yes, were representative of the other agencies, with parent consent, invited to the Services Plan meeting?
□
Yes
□
No (if no, why not?)
Describe the course(s) of study that focus on academic and functional achievement needed to assist the
student in reaching the above goals.
TRANSFER OF RIGHTS
Will the student reach his/her 17th birthday during the timeframe of the Services Plan or has the student
reached the age of 18?
□ Yes □ No
(If yes, specify how the student and parents have been informed of the rights which will transfer or have transferred to the
student at age 18 if no legal guardian has been appointed)
Rev. 11/07
CESA #10
725 W PARK AVENUE
CHIPPEWA FALLS WI 54729
SPECIAL EDUCATION DEPT.
(715) 723-0341
SCHOOL DISTRICT
PARENTAL CONSENT FOR PLACEMENT
Name of child (last, first, middle)
Date of birth
Gender
M
Name of parent or legal guardian
District of Residence
Grade Level
F
Address (street, city, state, zip)
District of Placement (if different)
Is this a public school choice
transfer?  Yes
 No
Before the school district can provide special education to your child as described in his/her Services Plan, your written
consent (permission) is needed. Your consent is voluntary and can be revoked prior to the initial provision of special
education. If you do not give your consent, the school district may not provide special education to your child.
I hereby give my consent to the
School District
for the special educational placement of my child
described in the Services Plan (Determination and Notice of Placement). I understand the action
proposed by the school district.
_________________________________________________________________
Signature of Parent or Legal Guardian
___________________________
Date
-OR-
I do not give my consent to the
School District for
the special education placement of my child
described in
the Services Plan (Determination and Notice of Placement). I understand the action proposed by the
school district.
_________________________________________________________________
Signature of Parent or Legal Guardian
___________________________
Date
You have previously received a statement of procedural safeguards. If you would like another copy of the procedural
safeguards available to you as the parent of a child with a disability or if you have questions about this information, please call:
_____________________________________________
Name and Title of District Contact Person
___________________________
_______________
E-mail Address
Phone
If you wish to contact someone other than the person indicated to discuss your rights, please refer to the parent and child rights brochure
for the names and telephone numbers of organizations you can contact, or call the Special Education Department at CESA #10, (715)
723-0341.
Rev. 11/07