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

Recommendations

Info

NASSAU COUNTY DEPARTMENT OF HEALTH EARLY INTERVENTION PROGRAM ABA TEAM MEETING ATTENDANCE SHEET Having participated in this team meeting, I agree to implement the goals, programs and behavior plans as discussed. Child:_________________________________________________________ Date:______/______/______ Time:_____________ EI 5195 4/05 NAME (Print) AGENCY SIGNATURE & TITLE
THOMAS R. SUOZZI COUNTY EXECUTIVE NASSAU COUNTY DEPARTMENT OF HEALTH OFFICE OF CHILDREN WITH SPECIAL NEEDS Early Intervention Program Preschool Special Education Program NOTIFICATION OF NON-DELIVERY OF AUTHORIZED SERVICES ABBY J. GREENBERG, M.D. ACTING COMMISSIONER BOARD OF HEALTH Norma J. Henriksen Chair Diana Coleman Vice-Chair Ellen J. Braunstein, M.D. Donna Kass The purpose of this form is to provide written information to the Nassau County Early Intervention Official Designee (EIOD) after telephone contact when the services contained in the IFSP are not being delivered in the manner authorized. This form is to be used by: 1. an independent contracted service provider or a service provider working for an agency. Either provider MUST notify the Ongoing Service Coordinator as soon as: • the child has missed five (5) consecutive sessions; or • there has been difficulty in delivering the services in the authorized manner. -OR- 2. the contracted Ongoing Service Coordinator to notify the Nassau County Early Intervention Official Designee as soon as: • the child has missed five (5) consecutive sessions; • there has been difficulty in delivering the services in the authorized manner; or • they anticipate or experience an inability to deliver services contained as written in the child’s IFSP. This notice should be forwarded within ten (10) days of the authorized start date of the service. TO: (Check the appropriate box) Date: ________/________/________ [ ] _________________________________________ [ ] _________________________________________ Name of Early Intervention Official Designee Name of Ongoing Service Coordinator FROM: (Check the appropriate box and complete the required information) [ ] _________________________________________ [ ] _________________________________________ Service Provider Ongoing Service Coordinator ___________________________________________________________________________________________________ Address (________)________________________________ (________)____________________________________ Phone Number Fax Number RE: Child’s Name: DOB: / / Check Reason(s) for Contact to EIOD: SERVICE TYPE:_________________________ AUTH. #:__________________________ RE: Child’s Name:_________________________________________________________ DOB:_________/_________/_________ [ ]Difficulty delivering services as authorized in the child’s IFSP. Auth. Start:_____/_____/_____ Auth. End:_____/_____/______ [ ]Inability to deliver services contained in the IFSP. Auth. Start:_____/_____/_____ Auth. End:_____/_____/______ [ ]Five (5) consecutive authorized services missed: Dates of Missed Sessions Reason(s) for Missed Sessions 1. _____/_____/_____ _______________________________________________________________________ 2. _____/_____/_____ _______________________________________________________________________ 3. _____/_____/_____ _______________________________________________________________________ 4. _____/_____/_____ _______________________________________________________________________ 5. _____/_____/_____ _______________________________________________________________________ AFTER THE PHONE CALL TO THE EIOD NAMED ON THE CHILD’S INDIVIDUALIZED FAMILY SERVICE PLAN, PLEASE DIRECT THIS NOTIFICATION OF NON-DELIVERY OF AUTHORIZED SERVICES BY FAX (516) 227-8662 EI 5201 3/07
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 and 14: HEALTH STATUS REPORT In compliance
Page 15 and 16: NASSAU COUNTY EARLY INTERVENTION PR
Page 17 and 18: Page ____ of ____ NASSAU COUNTY EAR
Page 19: THOMAS R. SUOZZI COUNTY EXECUTIVE N
Page 23 and 24: Child’s Name THOMAS R. SUOZZI COU
Page 25 and 26: THOMAS R. SUOZZI COUNTY EXECUTIVE N
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 ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?