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

NASSAU COUNTY DEPARTMENT OF HEALTH
EARLY INTERVENTION PROGRAM
60 Charles Lindbergh Blvd., Suite 100
Uniondale, NY 11553-3683
APPLIED BEHAVIORAL ANALYSIS
TEAM LEADER PROGRESS REPORT
FAMILY TRAINING
EIOD:
PLEASE CHECK IFSP PERIOD
[ ]3 Mo [ ]6 Mo [ ]9 Mo [ ]12 Mo [ ]15 Mo [ ]18 Mo [ ]21 Mo
[ ]24 Mo [ ]27Mo [ ]30 Mo [ ]33 Mo [ ]36 Mo [ ]39 Mo [ ]Discharge
(Please Type)
Only Original Forms will be Accepted Date of Report:
Child’s Name Date of Birth: CA: AA:
IFSP Period: FREQ/DURATION:
Provider/(Agency Name) & Discipline:
Team Leader Name/Title: License #
Team Leader Signature:
Key: C = Clinician cancelled FV = Family vacation H = Holiday I = IFSP meeting M = Make-up N = No one home
P = Parent cancelled PV = Provider vacation S = Child sick/hospitalized FT = Family Training X = Treatment session
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Month/Year:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Month/Year:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Month/Year:
Family/Caregiver Plan:
a. Specific suggestions/recommendations for family/caregiver to facilitate attainment of goals:
b. Describe family/caregiver involvement:
(If applicable) Date of Discharge: / /
Signature & Title: Date: / /
(Person Reviewing Report)
EI 5285 12/06