IEP Page 7 of 10

SERVICES

Name _______________________ IEP Date __/__/____

Service Options considered (in selecting LRE, consideration is given to any harmful
effect on the child or quality of services that the child needs:
___________________________________________________________________
___________________________________________________________________
*Service delivery model (Individual (I) Group (G))
Supplementary
Aide and
Services
Program
Start/End
Modifications * Provider Duration Frequency Location
Date
and/or
Supports for
School
Personnel

Start/End
Services Provider Duration Frequency Location
Date

Extend School Start/End

Provider Duration Frequency Location
Year (ESY) Date

Physical Education: General Modified General

Specially Designated: (describe)____________________
Service City: ______________________ Attendance School: ______________________

School Type Public Private Preschool Setting: _____ (For Kindergarten Student)

Mental Health:
✔ Student id eligible for Mental Health Services? YES NO
✔ Mental Health Service Language included on the IEP? YES NO

Student will NOT participate in the general education environment for

__________________________________________________________________________
__________________________________________________________________________

Extent student will NOT participate in general education classes and extracurricular activities
at least 70% of the time because _____________________________________

All special education services provided at student’s school of residence? YES NO

FORM 5 – SUPPLEMENTARY AIDS AND SERVICES