Personal Touch EIP Progress Note Checklist NYC Early Intervention Program

Encircled type of progress report Y N

Provider Progress Note PAGE 1

(Circle One) 3 , 6, 9, 12 month
If report is not typed, handwriting is legible Y Y Y Y Y Y Y Y Y N Y N

N Child’s name, correct spelling: (followed last name, first name) N IFSP Period, correct time frame ____ NOT per quarter N N N N N N DOB: ______ Provider Agency Name: ______________ Y Y

N EI ID #: _______ N Provider ID #: __________

Name of Interventionist: ______ FULL name and title Discipline: ____ (OT, PT, ST, SI, SW) Service Type: ____ (OT, PT, ST, SI, SW, or FT~Family Training) -- No other answers Authorization Frequency? _____________ (should indicate if it’s weekly or monthly) Y N Service Start Date: ______________ (regular service start date should NOT be the same as FT start date; these two dates should be different)


N Completed section under gaps in service delivery N If there was a gap, inclusive dates were noted. N If there was a gap, reason was noted.

MUST BE COMPLETED. State None if N/A. If there are any gaps in service delivery, (ie 3 or more consecutively scheduled visits), describe length and reason for gap in service delivery. ___________________ Y N Filled Out IFSP Outcomes Y N Checked Rate Progress in this time period RATE PROGRESS IN THIS TIME PERIOD Little Moderate Great Deal Outcome Progress Progress Progress Achieved

IFSP OUTCOME(S): _____________________ ______________________________________ ______________________________________ Y

No Progress

N Filled out section about how they worked with family to help child reach outcome

How did you work with the family to help the child to reach this outcome? ________________________________________ __________________________________________________________________________________________________

Provider Progress Note PAGE 2
Y N Y Y Y Y Y Y N N N Y Y Y Y N N N Section 1 filled out. N N N For 3rd and 9th month, need current developmental level of functioning in age or age range (in months) For 6th and 12th month, need percentage of delay. Stated how progress was determined (clinical opinion, dev.checklist, criterion-referenced instrument)

Section 2 filled out. – should not be left blank Section 3 filled out. – should not be left blank Section 4: Recommendations – should not be left blank; should state continuation at the current mandate and any new suggested goals N EI form submitted or letter of justification was written regarding any change in frequency, location, etc. Signature of interventionist Date filled out; should be when the clinician submitted the report (CANNOT BE BACKDATED or DATED in ADVANCE) License No. (Note: Only Special Educators are allowed NOT to write their license number)

Signature of interventionist completing report: ____________________ Date: ___________ License No. ______________ (If certified interventionist, do not indicate certificate number).