Justificationforchangeinfrequency,Intensity Ormethodofservices

NYCEARLYINTERVENTION PROGRAM

JUSTIFICATIONFORCHANGEINFREQUENCY,INTENSITY ORMETHODOFSERVICES

Child’s EI IDNumber: Child’s DOB: //

Child’s Name: LastFirst

Name ofProvider: Discipline:

Therapist Phone Number: () Agency Name: Name ofSupervisor: SupervisorPhoneNumber: ( )

Date of Submission to OSC:

AuthorizationInformation:All areas mustbe completedonthis formorit will bereturnedas incomplete.
IFSP StartDate: //IFSP End Date: //Authorized Service:
# of sessions authorized:
#of sessions delivered byprovider priortothisJustificationforChange:
# of sessions missed (due toeither provider or parent reasons):
Date(s)ofanyPreviousJustification for ChangeinthisDiscipline: //
RequestforChange(Complete all that apply):Terminationof ServiceIncrease/Change in Service
Frequency: From: times perTo: times per
Duration:From:_minutesTo: minutes
Method:From:To:
Required JustificationComponents:Justificationswill be returnedifall questions arenot answered.Responses must benumbered
and addressed inthebeloworder. For termination ofservice(s), completesections1,2, and 5 only.
1. CurrentFunction:
a.Whatisthechild’scurrentlevel offunction?
b.Ifanevaluationwasadministered,providethenameofthetest andthescore,unlessthisinformationisincludedin an evaluationreport.
c.Whatwasthechild’slevel offunctionat thelast IFSP?
d.Whatcanthechilddonow,that he/shewasunabletodopreviously(giveskill-basedexamples).
2. Service(s)Providedto Date:
a.Whendidyoubegindeliveryoftheservice?
b.Dida differentproviderdelivertheseservicesbeforeyouwereassigned?
c.Didservice(s)beginon time?
d.Explainanygapsinservice(s)including:missedsessions,frequentillness,vacationsetc. Includebothproviderand familyreasonswhenavailable.
3. Family Involvement:
a.Describehowyouaresupportingthefamilyand/orcaregiversinintegratingsuggestedactivities intothechild’sand family’sdailyroutines(Describespecificactivities).
b.Whatsuccessesordifficultieshasthefamilyhadinintegratingtheseactivities?
c.Whensuggestedactivities wereintegratedintoeverydayactivities, whatchangesinthedaily routineshaveyouobserved?
4. ServicePlanCoordination
a.Haveyoucoordinatedwithotherteam memberstoachieveIFSPoutcomes?
b.HaveyouaddressedthesameordifferentIFSPoutcomesasothertherapists?Explain.
5. IFSPOutcomes:
a.Whatis/are thefunctionaloutcome(s)that youarecurrentlyworkingonasstatedintheIFSP?
b.Whataretheshorttermobjectivesthat youarecurrentlyworkingontoreachthefunctionaloutcome(s)?
c.WhatprogresshasthechildmadetowardtheIFSPoutcomessinceinitiationofthisserviceplan?
d.Whatalternate strategieshaveyouusedtoreplaceineffectivestrategies?Havetheybeeneffective?
6. Whatwill therecommendedchangeofferthat thepresentplandoesnot?
a.Doestheproposedplanrecommenda newfunctionaloutcome?
b.Whatnew,shorttermobjectivesarebeingproposedtoreachthefunctionaloutcomes?
c.Whatarethenewstrategiesbeingproposedtoachievetheshorttermobjectives?
d.Will thenewplaninvolvestrategiesandmethodsthat cannotbereinforcedby activities that arepartofthechild’sdaily routine?Ifyes,describewhyandindicate ifchangesinthedailyroutinearepossible.
7. Listanychangesinthechild’smedicaldiagnoses,conditionsor medicationssincethelast IFSPwhichmayhaveanimpactonthe child’sreactiontoEIServices.Describehowa changeinthechild’smedical conditionor medicationswill affecttheservice deliveryplan.

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