Family Information Notebook (FIN) - Vanderbilt Kennedy Center

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Speech/Language Tests 20 CHILD’S NAME: DATE OF BIRTH: EVALUATIONS (Continued) Date Test Administered Given By Results _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ Child Development Tests Date Test Administered Given By Results _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ Psychiatric Tests Date Test Administered Given By Results _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ Other Tests and Exams Date Test Administered Given By Results _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ _________________ _______________________ ___________________ ______________________________________ © Junior League Family Resource Center 2005
At home: 21 CHILD’S NAME: DATE OF BIRTH: FAMILY / SOCIAL INFORMATION Who lives in the same house or apartment with your child? Please list their ages and relationship to your child. Include adults and other children. Name Age Relationship to child Name Age Relationship to child Who has legal custody of your child? Name: ________________________________________ Relationship to child: Who is the main person that takes care of your child during the day? Name: ________________________________________ Relationship to child: Who is the main person that takes care of your child during the evening? Name: ________________________________________ Relationship to child: Which recent changes or stressors in your family’s home, school, job, etc., might affect your child’s medical care or be helpful for medical staff to know about? _______ Change in financial situation _______ Change in work responsibilities _______ Child starting at a new school or program _______ Death of family member _______ Divorce / separation / marital problems _______ Move to a new residence _______ New family members (e. g. new baby or foster child, new spouse) In the Community: Please check any of the following social services your family is receiving: _______ WIC _______ Home-based early intervention services _______ HUG nurses _______ Other (please describe): _______________________________________ How do you usually get to the medical care facilities you use? Family car Rely on friend or neighbor Rely on relative Bus / public transportation _______ Parent beginning or leaving a job _______ Pregnancy or causing a pregnancy _______ Trouble at school_______ Other (please describe): _______________________ _______ Home Health _______ CSS (Children’s Special Services) _______ RIP (Regional Intervention Program) _______ Social Worker Taxi TennCare transportation No reliable transportation How do you most like to learn about health care information? _______ Videos _______ Talking to your child’s doctor or therapist _______ Books _______ Talking to other parents _______ Pamphlets _______ Other (please describe): _____________________________ _______ Internet © Junior League Family Resource Center 2005
Page 1 and 2: 1 Family Information Notebook (FIN)
Page 3 and 4: 3 TABLE OF CONTENTS Emergency Healt
Page 5 and 6: 5 INTRODUCTION TO EMERGENCY HEALTH
Page 7 and 8: CHILD’S NAME: DATE OF BIRTH: CURR
Page 9 and 10: CHILD’S NAME: DATE OF BIRTH: 9 BA
Page 11 and 12: CHILD’S NAME: DATE OF BIRTH: 11 A
Page 13 and 14: 13 MEDICAL POWER OF ATTORNEY I, ___
Page 15 and 16: 15 Health and Development • Intro
Page 17 and 18: CHILD’S NAME: DATE OF BIRTH: 17 M
Page 19: Eye Exams 19 CHILD’S NAME: DATE O
Page 23 and 24: 23 SUGGESTED INFORMATION TO INCLUDE
Page 25 and 26: 25 INTRODUCTION TO DAILY ROUTINE Th
Page 27 and 28: CHILD’S NAME: DATE OF BIRTH: 27 S
Page 29 and 30: 1. Equipment: Who provides (agency,
Page 31 and 32: CHILD’S NAME: DATE OF BIRTH: 31 M
Page 33 and 34: CHILD’S NAME: DATE OF BIRTH: 33 P
Page 35 and 36: CHILD’S NAME: DATE OF BIRTH: 35 T
Page 37 and 38: 37 INTRODUCTION TO EDUCATION / SCHO
Page 39 and 40: CHILD’S NAME: DATE OF BIRTH: Name
Page 41 and 42: Doctor Nurse Teacher CHILD’S NAME
Page 43 and 44: � TEIS Evaluations and ISPs � C
Page 45 and 46: INTRODUCTION TO RESOURCES / OPTIONA
Page 47 and 48: Your Child’s Educational Rights:
Page 49 and 50: 49 Kay Flowers, Complaints Consulta
Page 51 and 52: 51 State Special Schools Tennessee
Page 53 and 54: 53 TENNESSEE DEPARTMENT OF CHILDREN
Page 55 and 56: 55 ADDITIONAL EDUCATION AND HEALTH
Page 57 and 58: 57 SPECIAL EDUCATION MEDIATION REQU
Page 59 and 60: DUE PROCESS HEARING REQUEST FORM TE
Page 61 and 62: 61 INTRODUCTION TO APPENDICES SECTI
Page 63 and 64: Physical Therapist (PT): a licensed
Page 65 and 66: QUALITY HEALTH CARE • There are s
Page 67 and 68: 67 Month: _________________________
Page 69 and 70: F Page Family Resource Center Conta

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