ࡱ> EGD bjbjqq 40eeAAAAAUUUUqDUD l!R$RAAA AA'hc@U  0D $$ cc$Aw\D $ : NYC EARLY INTERVENTION PROGRAM JUSTIFICATION FOR CHANGE IN FREQUENCY, INTENSITY OR METHOD OF SERVICES Childs EI ID Number: ________________________________Childs DOB:____/____/____ Childs Name: Last__________________________________First_________________________________________ Name of Provider:__________________________________Discipline:____________________________________ Therapist Phone Number (_______)____________________Agency Name:_________________________________ Name of Supervisor: ________________________________Supervisor Phone Number: (____)_________________ Date of Submission to OSC:________________________ Authorization Information: All areas must be completed on this form or it will be returned as incomplete. IFSP Start Date:____/____/____ IFSP End Date:____/____/____ Authorized Service:_______________ # of sessions authorized:________________________________ # of sessions delivered by provider prior to this Justification for Change:__________________________ # of sessions missed (due to either provider or parent reasons):_________________________________Date(s) of any Previous Justification or Change in this Discipline: ____/____/____Request for Change (Complete all that apply): ( Termination of Services ( Increase/Change in Service(Frequency: From: _____ times per_______ To: ________ times per ________ (Duration: From: _____ minutes To: ________ minutes (Method From: ____________________ To: __________________________ Required Justification Components: Justifications will be returned if all questions are not answered. Responses must be numbered and addressed in the below order. For termination of service (s), complete sections 1, 2 and 5 only. 1. Current Function: a. What is the childs current level of function? b. If an evaluations was administered, provide the name of the test and the score, unless this information is included in an evaluation report. c. What was the childs level of function at the last IFSP? d. What can the child do now, that he/she was unable to do previously (give skill-based examples). 2. Service(s) Provided to Date: a. When did you begin delivery of the service? b. Did a different provider deliver these services before you were assigned? c. Did service(s) begin on time? d. Explain any gaps in service(s)including; missed sessions, frequent illness, vacations etc. Include both provider and family reasons when available. 3. Family Involvement a. Describe how you are supporting the family and/or caregivers in integrating suggested activities into the childs and familys daily routines (Describe specific activities). b. What successes or difficulties has the family had in integrating these activities? c. When suggested activities were integrated into everyday activities, what changes in the daily routines have you observed? 4. Service Plan Coordination a. Have you coordinated with other team members to achieve IFSP outcomes? b. Have you addressed the same or different IFSP outcomes as other therapists? Explain. 5. IFSP Outcomes: a. What is/are the functional outcome(s) that you are currently working on as stated in the IFSP? b. What are the short term objectives that you are currently working on to reach the functional outcome(s)? c. What progress has the child made toward the IFSP outcomes since initiation of this service plan? d. What alternate strategies have you used to replace ineffective strategies? Have they been effective? 6. What will the recommended change offer that the present plan does not? a. Does the proposed plan recommend a new functional outcome? b. What new, short term objectives are being proposed to reach the functional outcomes? c. What are the new strategies being proposed to achieve the short term objectives? d. Will the new plan involve strategies and methods that cannot be reinforced by activities that are part of the childs daily routine? If yes, describe why and indicate if changes in the daily routine are possible. 7. List any changes in the childs medical diagnosis, conditions or medications since the last IFSP which may have an impact on the childs reaction to EI services. 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