INSTRUCTIONS FOR REVISED PROVIDER PROGRESS

REPORTS

In accordance with the Early Intervention contract, the provider must complete a progress report for every
child every three months and when any amendment is requested. (Note: The Provider must maintain a copy
of the progress report on file.) COPIES OF ALL REPORTS MUST BE FORWARDED TO THE CHILD’S
PARENT(S), ON-GOING SERVICE COORDINATOR AND EIOD.

INSTRUCTIONS:
All progress reports are due at least five working days prior to any IFSP or Amendment meeting.

Please check one: [ ] 3 Month Report [ X ] 6Month Report [ ] Amendment

SECTION 1: OUTCOMES

OUTCOMES: (List outcomes which were designated in the IFSP for which you were reponsible. Note if they
have been attained, are emerging, or not achieved.)

INSTRUCTIONS:

In this section the outcomes that were designated in the IFSP are to be listed and the provider is to assess if these
outcomes have been: attained, are emerging or not achieved. If a child is able to perform a task then the outcome
has been achieved. It should be noted that at times all children choose not to do things even when they are able.

The following is an example of how to effectively complete this section:

1) John will eat solid foods and will accept various textures -EMERGING

2) John’s pattern of chewing will improve -EMERGING

3) John will drink from a sippy cup - EMERGING

4) John will have some signs and some word approximations/ true words that he spontaneously uses to
make requests - EMERGING

5) John will follow simple commands without a gesture being offered, e.g., “ Get your shoes.” -
ACHIEVED

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 SECTION 2 : PROGRESS TO DATE

PROGRESS TO DATE: (For child directed services, include: major interventions, formal and informal
assessments of developmental level, and current status of the child. For family training services indicate if the
family feels that the service is meeting their needs.) Indicate what techniques have been taught to the parent(s) or
caregiver(s) and incorporated into the family’s daily routine. AN ASSESSMENT SCORE MUST BE INCLUDED
IN EVERY 6 MONTH AND AMENDMENT REPORT.

INSTRUCTIONS:

Test scores are to be included in every six-month report. The tests that are utilized should be selected to
accurately reflect the child’s strengths and weaknesses. Scores are required if there is to be: 1) a discharge , 2) a
change in frequency or 3) a change in duration. In this section list the assessment tool utilized and the assessed level of
performance.

The following is an example of how to effectively complete this section:

John is currently 29 months old. He has a diagnosed condition and has been receiving services since birth. He currently
receives speech services, special instruction, physical therapy and occupational therapy. In addition to delayed speech
there are concerns with oral muscle strength and tone and chewing difficulties. John can drink from a sippy cup with
spillage. His oral motor tone does not allow for a tight seal on the cup. Although John’s chewing pattern has improved,
he still has low tone and poor oral motor skills.

John continues to be below normal weight and height for his age. According to Dr. Daniel Smith (“Feeding Difficulties”,
1998) John’s feeding skills are still not age appropriate. Improvement has been noted in John’s ability to eat foods of a
mashed consistency. He is starting to handle mixed textures. Some solid foods such as broccoli, grilled cheese
sandwiches, slices of cheese, rolls and muffins have been introduced. John is starting to nibble and take tiny bites of
these foods. He does not move food from side to side when chewing. John’s feeding skills are also compromised by
frequent ear infections which tend to make him gag more often.

John is imitating more word approximations. He is now heard to attempt to imitate the following words: light, pen,
watch, out and lunch. He is consistently and spontaneously using 13 words/word approximations. They include: Mama,
Dada, Papa, Maizie, Hi Maizie, clue, bye, baba/bottle, bu/book. He is jargoning, sometimes with inflection, and
continues to use some of the simple signs he was taught prior to his language emerging. John communicates nonverbally
using gestures or by pushing people. He produces at least six different consonant/vowel combinations, and varies the
sounds produced in syllable strings. He finds it difficult to imitate a word, name objects, produce a succession of single
word utterances, use one pronoun, use a question inflection or combine three or four words in spontaneous speech.

Receptively, John is able to follow simple verbal directives without a gesture. He can identify body parts, identify
pictures, understand spatial concepts, and recognize action in pictures. He is unable to understand verbs in context,
pronouns, quantity concepts, use of objects and part/whole relationships.

Assessment Tool Utilized: Assessed Levels of Perfomance:

Pre-School Language Scale 4 Auditory Comprehension – SS 73

Expressive Language – SS 70
Total Language Score – 72

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 SECTION 3: RECOMMENDATIONS OF PROVIDER OR TREATMENT TEAM:

RECOMMENDATIONS OF PROVIDER OR TREATMENT TEAM: Please check the appropriate box. If a

continuation of services is recommended include information that supports this recomendation. If there is a
recommendation for a change in the delivery of services indicate the specific change and provide a rationale. (If
appropriate, the Team Leader fills out the recommendation of the team.)
Please check one: [ ] Discharge [ ]Decrease [ x ] Continue [ ] Increase

I have been informed by my child’s therapist and agree that my child is no longer in need of, nor eligible for,
Early Intervention Services provided by Suffolk County.
Parent’s Signature: ___________________________ Date: __________________

INSTRUCTIONS:

In this section you will be asked to provide a justification for recommending: 1) a discharge from services, 2) a decrease
in services, 3) a continuation of existing services 4) an increase in services . The justification is based upon standardized
test scores and informed clinical opinion.

Clinical opinion is part of every determination of the need for services. Informed clinical opinion makes use of both
qualitative and quantitiative information to assist in forming a decision about eligibility. It includes a description of the
child’s functional status, rate of change in development, and prognosis. It is used to augment the findings of standardized
testing.

Clinical opinion should be supported by professional judgment when there are no standardized tests available.
Professional judgment is the use of expert research to support the therapist’s informed clinical opinion that the child has
a developmental delay.

Every child would benefit from services but children remain eligible for services only as long as they continue to have
a documented delay.

If progress has not been sufficient, a recommendation for a change in frequency or duration of services may be
appropriate. At times a change in therapists may be warranted. If progress towards reaching age appropriate goals has
been made, but some delay is still evident, the therapist may recommmend a decrease in services. Therapists should
recommmend a discharge once a child approaches age appropriate levels. This should be substantiated by standardized
scores or professional judgment. Discharge should be discussed with the parents and they should be made aware of
ongoing strategies that they can use to foster their child’s development. It is important to remember that a large part of
the intervention process is training parents to help their children progress. When it is time to discontinue therapy,
parents should feel competent enough to work with their children based upon parent training that you have provided
throughout the course of intervention. A discharge recommendation now requires a parent signature.

The following is an example of how to effectively complete this section:

Justification:

John is a 29 month old child who continues to exhibit a > 25% delay in his total languge score on the PLS 4. In addition
to this language delay, John exhibits poor oral motor tone and control. This is seen through John’s inability to drink
from a cup without spillage and his inability to move food inside his mouth from side to side. At his age John should be
able to drink from any kind of cup without spillage. According to Dr. Daniel Smith (1998), children who are over 18
months of age should have sufficient oral motor control to be able to drink from a cup without spillage.

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 SECTION 4: FUNCTIONAL OUTCOMES AND STRATEGIES

FUNCTIONAL OUTCOMES AND STRATEGIES: List strategies that can be used by parent (s) and
service providers to improve this child’s development. Indicate all techniques taught to parent(s)
and/or caregiver(s) that can be incorporated into the family’s daily routine.

INSTRUCTIONS:

In this section the therapist is to identify strategies that will be used by parents on a daily basis to elicit functional
outcomes. Parent training is one of the most important ways that we can help children progress. Therapists should
instruct parents in techniques that the family can easily utilize and incorporate into their daily routines. By incorporating
these strategies, the parent’s involvement becomes the essential component of the Early Intervention process that it is
meant to be.
C.P.T. Codes must now be added to this section that reflects the methodology of each strategy.

The following is an example of how to effectively complete this section:

In the case of the child, John, that we have been using as our sample, the parents are very concerned about John’s poor
feeding skills. They want him to eat thicker and more varied foods, use a sippy cup and be able to feed himself with a
spoon. The therapist could offer the parents the following strategies:

Functional Outcomes: Strategies: C.P.T. Codes

To accept a variety of textures Add cereals to food to make them thicker.

To drink from a cup Use a Nuk stimulator to increase oral strength

and tone so that the child can get a tight seal
on the cup.

To eat with a spoon Place your hand over child’s hand to help
in scooping food from a scoop dish.

Build up the handle of a spoon with guaze and

tape so that it is easier for the child to use.

These outcomes can be worked on during meal or snack time.

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 SECTION 5: PROVIDER SIGNATURES

I certify that I have received a copy of this child’s IFSP prior to the commencement of services and
that I have provided the above stated services in accordance with the frequency and duration
authorized in that IFSP. Additionally, I certify that my responses in this report are an accurate
representation of this child’s current level of functioning .

Service Provider’s Signature: _____________________________ Date: __________________

Please Print Name: ________________________________
Service Provider’s License or Certification: ____________________________ #: ___________________

INSTRUCTIONS:
In this section the provider signs and dates the above certification, prints his/her name, and indicates his/her credentials
including license or certification #.

If appropriate Team Leader completes this section:

Present at Treatment Team Meeting:
Team Member: ____________________________ Discipline:
__________________
Team Member: ____________________________ Discipline:
__________________
Team Member: ____________________________ Discipline:
__________________
INSTRUCTIONS:
If there has been a treatment team meeting the names of the attendees must be listed. Please print.

SECTION 6: AUTHORIZED UNITS -- FREQUENCY, DURATION, AND UTILIZATION

In this section utilization of the units of service authorized is detailed. Please note, it is important to keep track of the
number of units authorized so that you do not exceed this number. It is also important to monitor missed sessions. If the
child has missed more than 5 consecutive sessions a separate notification and an explanation must be sent to the EIOD.
Remember, that it is important for all providers to know the child’s schedule so that missed sessions are not made up in a
way that interferes with the billing regulations.

The following is an example of how to effectively complete this section:

IFSP Authorized Units: 52 Frequency/Duration: 2x wk / 45 min.

(Circle days of session) Sun / Mon / Tues / Wed / Thurs / Fri / Sat
# of Units Utilized: 42 Times of Therapy: Mon.@ 10:00 & Thurs.@ 11:00
# of Units Not Utilized Due to Child’s Illness, Family Vacation, Etc.: 5
# of Units Not Utilized Due to Therapist’s Illness, Scheduling, Etc.: 2
# of Units Not Utilized Due to School Calendar: 3

USE OF THE REVISED PROGRESS REPORT IS EFFECTIVE IMMEDIATELY.

Your cooperation is appreciated.