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

EARLY INTERVENTION PROGRAM
NASSAU COUNTY DEPARTMENT OF HEALTH
60 Charles Lindbergh Blvd., Suite 100
Uniondale, NY 11553-3683
3 MONTH PROGRESS REPORT
(Please Type)
Only Original Forms will be Accepted Date of Report:
EIOD:
Child’s Name Date of Birth: CA: AA:
IFSP Period: FREQ/DURATION:
Provider/(Agency Name) & Discipline:
Name/Title of Person Completing Report: License #:
Signature of Person Completing Report:
Check as appropriate: ( )3 Mo. ( )9 Mo. ( )15 Mo. ( )21 Mo. ( )27 Mo. ( )33 Mo. ( )39 Mo ( )Discharge
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 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:
PROGRESS TO DATE (What is specific to your sessions, include behavioral observations and interaction with family.)
Signature and title of person reviewing report _____________________________________________________________
EI 5078 9/06