Early Childhood Intervention Agency

Important Steps, Inc. Early Childhood Intervention Agency

JUSTIFICATION LETTER

Child’s Name: ______DOB: ______Child’s EI ID #: ______

 Request for additional ______Evaluation

______I. CURRENT FUNCTIONING: (Outcomes worked on and met. Child’s response to services)

II. CONCERNS/REASON FOR REQUEST (Explain the request for change in frequency/duration or request for an additional evaluation. Use specific examples)

III. RATIONALE FOR REQUEST (Why does a child need evaluation? Include the statement if parent agree with recommendations)

Therapist’s Signature: ______Discipline Date