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Application for Interim Instructional Services, with Qualified Mental Health Condition ONLY

About this Form

Form number: 311-15D

Audience:  Parents/Guardians, School Staff

Last revised: August 2020

Related Forms

Form 311-15E - Application for Interim Instructional Services,with Qualified Physical Health Condition ONLY

Note: This form is used by the Interim Instructional Services (IIS) Office to obtain psychiatrist’s/psychologist’s recommendation and parent/guardian permission to initiate instruction for students with a mental health condition. Return completed application to student’s school counselor or principal/designee.

A new completed application is required for continuation of service beyond 60 calendar days.

For more information, see MCPS Regulation IOE-RB, Interim Instructional Services.

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