APPENDICES FORMS Word Documents EI 5031 ATD Request EI ...

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PARENTAL CONSENT TO OBTAIN/RELEASE INFORMATION Child’s Name: Date of Birth: / / I, , give my consent to have my child’s records released to Name of Parent/Guardian (Please Print) Nassau County Department of Health Early Intervention Program. Signature of Parent/Guardian Date PHYSICIAN RECOMMENDATIONS & REFERRALS Please indicate which of the medical specialty areas this child has visited or been referred: Referred Date Visited Developmental Pediatrician _______ __________ Visual/ Opthamologist _______ __________ ENT/Hearing _______ __________ Neurologist _______ __________ Cardiologist _______ __________ Orthopedist/ Physiatrist _______ __________ Neo-Natal Spec. _______ __________ Gastro-Intestinal _______ __________ Genetic Testing _______ __________ Audiological _______ __________ Physical Thpy. _______ __________ Occupational Thpy: _____ __________ Speech Thpy. _______ __________ EI 5167.B 08/06 CLINICAL IMPRESSIONS & RECOMMENDATIONS Indicate all chronic conditions and/or findings needing follow-up: 1. ______________________________________ 2. _______________________________________ DIAGNOSIS & ICD 9 CODE: __________________________________________ __________________________________________ This child is being referred because he/she is suspected of having a disability, which includes a developmental delay and/or a diagnosed physical or mental condition that has a high probability of resulting in developmental delay. Physician Signature Print Name__________________________________ Address_____________________________________ ___________________________________________ Phone No.___________________________________ License No.__________________________________ _____
NASSAU COUNTY EARLY INTERVENTION PROGRAM IFSP REVIEW PLAN: [ ]6 Months [ ]18 Months [ ]30 Months Child’s Name__________________________________________________Childs DOB______/______/____________Date______/______/______ Outcomes Achieved/Current Level of Functioning: Ongoing/New Concerns/New Outcomes: Measures of Success: Strategies (Include assistive tech. devices, supplemental evaluations, specific changes in services, etc.): � IFSP Transition Guidelines reviewed with family. Last Date of EI Eligibility / / List changes in day care, insurance, work #, pediatrician, service coordination, transportation and/or reasons why services are not provided in natural environment: � Transportation: � Not Applicable � Parent � Bus/Reason IFSP Review Participants: I have reviewed the IFSP with my coordinator, and agree with the above IFSP Review Plan. Parent/Legal Guardian Signature ______/______/______ EIOD Signature__________________________________________________________________________________________________ ______/______/______ EI 5170.8 NCR 5/06 Distribution: White: EIP Yellow: Provider Pink: Parent/Guardian
Page 1 and 2: Nassau County Department of Health
Page 7 and 8: NASSAU COUNTY DEPARTMENT OF HEALTH
Page 9 and 10: EARLY INTERVENTION PROGRAM NASSAU C
Page 13: HEALTH STATUS REPORT In compliance
Page 17 and 18: Page ____ of ____ NASSAU COUNTY EAR
Page 19 and 20: THOMAS R. SUOZZI COUNTY EXECUTIVE N
Page 23 and 24: Child’s Name THOMAS R. SUOZZI COU
Page 27 and 28: Part II OSC/EIOD___________________
Page 29 and 30: THOMAS R. SUOZZI COUNTY EXECUTIVE C
Page 31 and 32: THOMAS R. SUOZZI COUNTY EXECUTIVE D
Page 33 and 34: Recommended Childhood and Adolescen
Page 35 and 36: (Team Leader to complete Part I fir
Page 41 and 42: THOMAS R. SUOZZI COUNTY EXECUTIVE S

APPENDICES FORMS Word Documents EI 5031 ATD Request EI ...

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