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

Nassau County Department of Health
Early Intervention Program
Child’s Name:
Evaluation: Summary Narrative
Include the following: (use additional pages as necessary)
EVALUATION SUMMARY
Evaluation Team
(Page 3of 3)
1. description of the assessment process & condition
2. the child’s responses
3. the family’s belief of whether the child’s response was optimal
4. an explanation of the scores & measures reported
5. statement of eligibility
*Attach a copy of the Health Status Report completed by the primary care provider
and incorporate any information provided by physician into summary narrative.
Date Evaluation was discussed with family: / /
Evaluation Report sent by (provider name)
To family on / / .
Narrative Completed by:
EI 5035.3 8/06
Name Title Date