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

THOMAS R. SUOZZI
COUNTY EXECUTIVE
Nassau County
DEPARTMENT OF HEALTH
OFFICE OF CHILDREN WITH SPECIAL NEEDS
Early Intervention Program
Preschool Special Education Program
Physically Handicapped Children’s Program
60 Charles Lindbergh Blvd., Suite 100
Uniondale, NY 11553-3683
EARLY INTERVENTION TRANSITION NOTICE-PARENT CONSENT
TO: EIOD: EIOD PHONE: 516-227-
Early Intervention Official DATE: / /
Nassau County Department of Health
Early Intervention Program
School District
CHILD’S NAME: DOB: / /
CHILD’S ADDRESS:
CHILD’S PHONE:
I understand that as of my child’s third birthday my child will no longer be eligible for Early Intervention
services unless a Committee for Preschool Education (CPSE) evaluation and meeting was held and he/she
has been found eligible for services under Section 4410 of the Education Law.
In order to initiate the transition process to determine continued eligibility my child must be referred to my local
school district CPSE. The choices below are only for transition information. Please choose from option I, II or option III.
I. [ ] CPSE Transition Process already initiated.
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
II. [ ] I give consent to the Nassau County Early Intervention Program to notify my local CPSE and
release/obtain pertinent information. I wish to begin the transition process.
(Therefore choose A or B)
A. [ ] I do not request a transition planning conference but I want to begin the transition
process for my child to the CPSE of my school district. Foregoing the planning
conference will in no way interfere with receiving a timely evaluation to determine
eligibility for CPSE services.
B. [ ] I request a transition planning conference with my Ongoing Service Coordinator and a
CPSE representative from my school district to explain the CPSE process and CPSE
services. This meeting will be arranged by the Early Intervention Official Designee and
will be held at least 90 days before my child is first eligible for services under
CPSE. The purpose of this meeting will decide the need for a referral to CPSE.
Eligibility will not be determined at this conference. OR
III. [ ] I do not request the Nassau County Early Intervention Program to notify my local school district
CPSE to begin the transition process for my child. I understand my child will no longer be
eligible to receive Early Intervention services after his/her third (3 rd ) birthday if eligibility has not
already been determined by my school district CPSE.
Date / /
Parent/Surrogate/Guardian Signature
EI 5224.1 02/07 Date Mailed to School District / /