APPENDICES FORMS Word Documents EI 5031 ATD Request EI ...
APPENDICES FORMS Word Documents EI 5031 ATD Request EI ...
APPENDICES FORMS Word Documents EI 5031 ATD Request EI ...
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NASSAU COUNTY DEPARTMENT OF HEALTH EARLY INTERVENTION PROGRAM<br />
IFSP REVIEW REQUEST/AMENDMENT<br />
Child's Name Child's DOB / /<br />
Name of <strong>EI</strong>OD <strong>Request</strong> Date / /<br />
<strong>Request</strong> submitted by Discipline/Title/Agency<br />
�Parent �Provider �Other<br />
Reason(s) for change in services or need for Supplemental Evaluation:<br />
Signatures: Therapist Parent Date: / /<br />
(DOH Use Only) Department of Health, in conjunction with family, therapist(s), Ongoing Service Coordinator agree upon:<br />
� Supplemental Evaluation Authorized <strong>EI</strong>OD Signature Date: / /____ �<br />
Current IFSP will not be amended at this time<br />
� Community programs and resources discussed with family<br />
� New outcome(s), strategy(s):__________________________________________________________________________________________<br />
� Amended Services:_________________________________________________________________________________________________<br />
� Changes will begin in two weeks � Changes will begin at new IFSP period<br />
� Transportation: � Not Applicable � Parent � Bus/Reason_______________________________________________________<br />
� Reason why services are not provided in natural environment________________________________________________________________<br />
Parent/Legal Guardian Signature Date _ / _ /_____<br />
Early Intervention Official Signature Date _ / _ /_____<br />
Once signed, this page becomes part of the IFSP.<br />
<strong>EI</strong> 5093. NCR 7/05 Distribution: DOH <strong>EI</strong>P: White Provider: Yellow Parent: Pink DOH <strong>EI</strong>P: Gold
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