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PHYSICIAN’S PLAN OF TREATMENT – TRANSITION PLAN
The purpose of this form is to outline a plan to transition the student back into the classroom, even if that plan is for the
student to remain receiving homebound services.
Patient (Student Name):
(Student DOB):
A. Current disabling condition (describe):
B. Describe why the disabling condition continues to prevent the student from attending school:
C. Please indicate specific steps planned to return the student to classroom instruction:
Presently, it is recommended for this student to (check as appropriate):
a.
continue receiving homebound services
Est. date to return to school
_3 weeks_________4-8 weeks ________other: please explain
b.
return to school for a:
¼ day
½ day
¾ day
total day
Recommended accommodations:
D. Briefly describe how treatment will be administered and how the student’s progress will be
monitored.
Failure to secure necessary assessments/tests within the initial approved homebound period is not a valid
reason f o r an extension of services.
Name of licensed physician/psychologist/psychiatrist completing form:
(Print)
Signature of Licensed Physician/ Psychologist/Psychiatrist/Nurse Practitioner
Date Signed :
Mail or Fax Forms to:
Homebound Office
Gatewood Learning Center
1241 Gatewood Road
Newport News, VA 23601
(757) 888-3352 (fax)Jump to an indexed page (2 of 2)