Early Intervention

EARLY INTERVENTION PROGRESS SUMMARY FORM

CHILD’S CHILD’S DATE OF BIRTH: REASON FOR REPORT (CHECK ALL THAT APPLY) FIRST NAME: LAST NAME: PREPARATION FOR IFSP REVIEW TRANSITION OUT OF NJEIS PERIODIC REVIEW COUNTY SERVICE COORDINATOR: CHRONOLOGICAL AGE: CHILD TURNING AGE 3/  6 MONTH (SCHEDULED) OF RESIDENCE: PREPARATION FOR  TO CONSIDER MODIFYING SERVICE TYPE/ FREQUENCY: TRANSITION PLANNING CURRENT IFSP DATE: SERVICES(UNSCHEDULED) CONFERENCE _____ DEVELOPMENTAL INTERVENTION ANNUAL REVIEW MEETING TRANSITION PRIOR TO 3 INITIAL ELIGIBILITY TYPE: _____ OCCUPATIONAL THERAPY OTHER: ______ DEVELOPMENTAL DELAY _____ PHYSICAL THERAPY REASON:  1 AREA (-2.0 SD) _____ SPEECH THERAPY ______ 2 OR MORE AREAS (-1.5 SD) _____ FAMILY TRAINING  INFORMED CLINICAL OPINION _____ OTHER ______ HIGH PROBABILITY/ PRESUMPTIVE DIAGNOSIS (LIST): ______

ONGOING ASSESSMENT  PARENT REPORT INSTRUMENT(S)/ CURRICULUM(S) IMPLEMENTED DEVELOPMENTAL STATUS SUMMARY  INFORMED CLINICAL OPINION/  INSTRUMENT(S)(LIST ALL) OBSERVATION INCLUDE SCORES/ AGE LEVELS ETC, & CATEGORIZE LEVEL OF PROGRESS. ______ REVIEW OF RECORDS (EDUC/ MED/ RIEFLY SUMMARIZE ALL AREAS OF DEVELOPMENT BY OR MORE PRACTITIONERS B ( 1 ). ______ETC.) ADDRESS STRENGTHS & NEEDS FOR EACH DEVELOPMENTAL AREA. ______ OTHER (LIST): ______CURRENT SCORES WHAT’S HAPPENING NOW NEXT STEPS FOR LEARNING IDENTIFY FUNCTIONAL SKILLS NEEDED TO PARTICIPATE IN DESCRIBE CURRENT FUNCTIONAL ABILITIES WITHIN EVERYDAY EVERYDAY ROUTINES ROUTINES

COMMUNICATION:

PROGRESS VS. CHRONOLOGICAL AGE  ABOVE TYPICAL RANGE FOR AGE  WITHIN TYPICAL RANGE FOR AGE  BELOW TYPICAL RANGE FOR AGE

COGNITIVE:

GROSS MOTOR:

FINE MOTOR:

SOCIAL EMOTIONAL:

PROGRESS VS. CHRONOLOGICAL AGE  ABOVE TYPICAL RANGE FOR AGE  WITHIN TYPICAL RANGE FOR AGE  BELOW TYPICAL RANGE FOR AGE ADAPTIVE:

Revised Oct 2013. Mid-Jersey CARES REIC PROGRESS VS. CHRONOLOGICAL AGE  ABOVE TYPICAL RANGE FOR AGE  WITHIN TYPICAL RANGE FOR AGE  BELOW TYPICAL RANGE FOR AGE

DISCUSSION: HOW HAS THE FAMILY BEEN ABLE TO USE EI STRATEGIES WITHIN HOME & COMMUNITY ROUTINES?

HOME ACTIVITIES (E.G., BATH TIME, MEALTIME, DIAPERING, FAMILY TIME, COMMUNITY ACTIVITIES (E.G., SHOPPING, PARKS, LIBRARY, VISITING RELATIVES/ READING, LAUNDRY, GOING PLACES, ETC.) FRIENDS, ATTENDING RELIGIOUS EVENTS, ETC.)

SUGGESTED STRATEGIES TO ADDRESS CHILD & FAMILY OUTCOMES : DESCRIBE INSTRUCTIONAL STRATEGIES, TECHNIQUES AND ADAPTATIONS TO SUPPORT THE CHILD’S PARTICIPATION IN AGE-APPROPRIATE ACTIVITIES.

KEEP DOING:

STOP DOING:

START DOING:

OTHER INFORMATION SHARED BY THE FAMILY (E.G., ONGOING OR NEW CONCERNS, FAMILY ROUTINES, CHANGE IN FAMILY CIRCUMSTANCES, CHANGE IN HEALTH/ MEDICAL INFORMATION, ETC.) (OPTIONAL/ IF NEEDED)

THE FOLLOWING MEMBERS OF THE IFSP TEAM HAVE PARTICIPATED IN PREPARING THIS SUMMARY. WE UNDERSTAND THAT THE IFSP TEAM WILL REVIEW PROGRESS TOWARD OUTCOMES & DECIDE TOGETHER WHAT SERVICES/ SUPPORTS ARE NEEDED TO REACH THE OUTCOMES AT THE IFSP REVIEW MEETING.

PARTICIPANTS ROLE AGENCY SIGNATURE DATE

PARENT/ GUARDIAN N/A

CONTACT INFORMATION FOR PRACTITIONERS: (EMAIL & PHONE) EARLY INTERVENTION PROGRESS SUMMARY FORM .

Revised Oct 2013. Mid-Jersey CARES REIC ADDENDUM/ ADDITIONAL NOTES (OPTIONAL)