Valley Central School District

Office of Special Education

120 Broadway
Maybrook, NY 12543
Phone: (845) 457-2400 Fax: (845) 457-8590

Prescription for Occupational Therapy Services

Student Name: Drake James Date of Birth: 04/28/2014

Disability: Multiple Disabilities Ordering/Referring Provider:

Recommended School: Berea Elementary Home School: Walden Elementary
I recommend that this student receive Occupational Therapy in accordance with the frequency and duration indicated on
the Individualized Education Plan (IEP)/504 Accommodation Plan.
Related Service Ratio Freq Duration Period Start Date End Date
Occupational Therapy Individual 1 30 minutes Weekly 09/13/2023 06/13/2024
Occupational Therapy Small Group 1 30 minutes Weekly 09/13/2023 06/13/2024
Occupational Therapy Small Group 1 30 minutes Weekly 07/03/2023 08/11/2023

Reason for Prescription:

ICD-10 Code(s): ________________________________________________________________________________

Reason/Need for Treatment: _____________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Well Child Check: Provider:

Precautions/Contraindications: ___________________________________________________________________

_______________________________________________________________________________________________

___________________________________________________ ___________________________________________
Signature, Ordering/Referring Provider Date (Must be filled in)
(Signature Stamp Not Allowed)

NPI (Must be filled in) License Number Credential

Ordering provider's contact information (office stamp or preprinted address and telephone number)

Name_______________________________________________________________________________________
Address_____________________________________________________________________________________
City, State, Zip________________________________________________________________________________
Telephone__________________________________________Fax______________________________________

Please fax or mail completed form to district.

 Valley Central School District
Office of Special Education
120 Broadway
Maybrook, NY 12543
Phone: (845) 457-2400 Fax: (845) 457-8590

Prescription for Physical Therapy Services

Student Name: Drake James Date of Birth: 04/28/2014

Disability: Multiple Disabilities Ordering/Referring Provider:

Recommended School: Berea Elementary Home School: Walden Elementary
I recommend that this student receive Physical Therapy in accordance with the frequency and duration indicated on the
Individualized Education Plan (IEP)/504 Accommodation Plan.
Related Service Ratio Freq Duration Period Start Date End Date
Physical Therapy Individual 2 30 minutes Weekly 09/13/2023 06/13/2024
Physical Therapy Individual 1 30 minutes Weekly 07/03/2023 08/11/2023

Reason for Prescription:

ICD-10 Code(s): ________________________________________________________________________________

Reason/Need for Treatment: _____________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Well Child Check: Provider:

Precautions/Contraindications: ___________________________________________________________________

_______________________________________________________________________________________________

___________________________________________________ ___________________________________________
Signature, Ordering/Referring Provider Date (Must be filled in)
(Signature Stamp Not Allowed)

NPI (Must be filled in) License Number Credential

Ordering provider's contact information (office stamp or preprinted address and telephone number)

Name_______________________________________________________________________________________
Address_____________________________________________________________________________________
City, State, Zip________________________________________________________________________________
Telephone__________________________________________Fax______________________________________

Please fax or mail completed form to district.

 Valley Central School District
Office of Special Education
120 Broadway
Maybrook, NY 12543
Phone: (845) 457-2400 Fax: (845) 457-8590

Prescription for Psychological Counseling Services

Student Name: Drake James Date of Birth: 04/28/2014

Disability: Multiple Disabilities Ordering/Referring Provider:

Recommended School: Berea Elementary Home School: Walden Elementary
I recommend that this student receive Psychological Counseling Services in accordance with the frequency and duration
indicated on the Individualized Education Plan (IEP)/504 Accommodation Plan.
Related Service Ratio Freq Duration Period Start Date End Date
Psychological Small Group 1 30 minutes Weekly 09/13/2023 06/13/2024
Counseling Services

Reason for Prescription:

ICD-10 Code(s): ________________________________________________________________________________

Reason/Need for Treatment: _____________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Well Child Check: Provider:

Precautions/Contraindications: ___________________________________________________________________

_______________________________________________________________________________________________

___________________________________________________ ___________________________________________
Signature, Ordering/Referring Provider Date (Must be filled in)
(Signature Stamp Not Allowed)

NPI (Must be filled in) License Number Credential

Ordering provider's contact information (office stamp or preprinted address and telephone number)

Name_______________________________________________________________________________________
Address_____________________________________________________________________________________
City, State, Zip________________________________________________________________________________
Telephone__________________________________________Fax______________________________________

Please fax or mail completed form to district.

 Valley Central School District
Office of Special Education
120 Broadway
Maybrook, NY 12543
Phone: (845) 457-2400 Fax: (845) 457-8590

Prescription/Referral for Speech/Language Therapy Services

Student Name: Drake James Date of Birth: 04/28/2014

Disability: Multiple Disabilities Ordering/Referring Provider:

Recommended School: Berea Elementary Home School: Walden Elementary
I recommend that this student receive Speech/Language Therapy in accordance with the frequency and duration indicated
on the Individualized Education Plan (IEP)/504 Accommodation Plan.
Related Service Ratio Freq Duration Period Start Date End Date
Speech/Language Small Group 2 30 minutes Weekly 09/13/2023 06/13/2024
Therapy
Speech/Language Small Group 2 30 minutes Weekly 07/03/2023 08/11/2023
Therapy

Reason for Prescription:

ICD-10 Code(s): ________________________________________________________________________________

Reason/Need for Treatment: _____________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

Well Child Check: Provider:

Precautions/Contraindications: ___________________________________________________________________

_______________________________________________________________________________________________

___________________________________________________ ___________________________________________
Signature, Ordering/Referring Provider Date (Must be filled in)
(Signature Stamp Not Allowed)

NPI (Must be filled in) License Number Credential

Ordering provider's contact information (office stamp or preprinted address and telephone number)

Name_______________________________________________________________________________________
Address_____________________________________________________________________________________
City, State, Zip________________________________________________________________________________
Telephone__________________________________________Fax______________________________________

Please fax or mail completed form to district.