Growing in Beauty Early Childhood Intervention Program
Name: / Referred by:
DOB: / Referral Date:
Chronological Age: / Date of Evaluation:
ICD-9: / Primary Language:
Parent’s / Guardian’s Name:
Address:
Evaluation Location:
Evaluation Team:
NAME / TITLEService Coordinator
Developmental Specialist II or III
Physical Therapistor Speech-Language Pathologist
Parents
Other
______
Reason for Referral
Background/Health History:
Vision Status:
Hearing Status:
Assessment Information:
Information for this assessment was collected through parent interviews, observations, and the use of Infant-Toddler Developmental Assessment (IDA). The Infant-Toddler Developmental Assessment (IDA) tool is designed to evaluate the child’s overall development. The IDA looks at eight (8) areas of development: Gross Motor (How the child uses his/her muscles to roll, sit, crawl, walk and balance during play), Fine Motor (How the child uses his/her hands and eyes together during play), Relationship to Inanimate Objects (How the child learns, thinks, plays, and problem solves with the use of toys and other objects in the home), Language/Communication (How the child understands and expresses his/her needs using words and gestures), Self Help (How the child performs self-care such as toileting, bathing, feeding, dressing and self-regulation), Relationship to Persons (How the child relates to and interacts with adults and other children), Social/Emotional (How the child expresses and controls feelings and emotions), and Coping Behavior (How the child uses his/her skills to meet daily demands and opportunities). The IDA allows the evaluation team to learn more about the child’s relationship with his/her family so they can provide a comprehensive evaluation to provide services and support.
(Evaluators: this is where you will describe the child’s skills in narrative paragraph format.)
Information regarding child’s daily routine & activities:
Evaluation Summary:
Following are the performance age ranges in all areas of the IDA: Gross Motor: ____ months, Fine Motor: ____ months, Relationship to Inanimate Objects: ____ months, Language/Communication: ____ months, Self-Help: ____ months, Relationships to Persons: ____ months, Emotions and Feeling States: ____ months, and Coping Behavior: ____ months.
(Note to evaluators: please choose from the following descriptors to review the child’s performance on the IDA: There are specific terms used in the discussion of results/impressions of performance of tasks or skills presented on the IDA. The first term is Competent, meaning that a child is demonstrating the behaviors or skills that are typically observed for a child within a specific age range. To be considered as Competent, a child must demonstrate that these skills are well established and would be observed in the child’s everyday life. The second term is Of Concern. There are three categories used to describe the degree of concern: Questionable, Delayed and Problematic. Questionable Concern is a term used when the findings of the evaluation are unclear. This may be because skills are emerging, the quality of the child’s performance may be poor or there are other reasons for uncertain findings. This may indicate that more specific evaluation is warranted. Of Concern-Delayed is a term used when a child’s performance in a specific domain would be more typical of a child at a younger age. Finally, the term Problematic Concern would be used to indicate qualitative concerns in the child’s development, such as wide variation on function between domains.)
Compliance and Eligibility
Based on the results of this evaluation, ____ does/does not appear to meet the Part C definition of a child who is eligible to receive early intervention services under the eligibility of developmental delay, due to a ___% delay in the area of ______.
The evaluation was completed in compliance with the Individuals with Disability Act (IDEA) Part C and the requirements for the Family Infant Toddler Program-Early Intervention Services (7 NMAC 30.8).
The type and frequency of services needed will be determined by the IFSP team based on the desired outcomes developed with the family.
Recommendations
The following is recommended for _____:
Signatures:
______
Service CoordinatorDate
______
Developmental SpecialistDate
______
Physical Therapist or Speech-Language PathologistDate
CME Report for
DOB: