CHILD’S LAST NAME   CHILD’S FIRST NAME 

504 FOR CHILD’S NAME SCHOOL YEAR SCHOOL YEAR JUVENILE
ACCIDENT REPORT CHILD’S NAME DATE OF ACCIDENT TIME OF
ADHD RATING SCALEIV CHHHC HOME VERSION CHILD’S NAME GENDER

ALL ABOUT ME CHILD’S NAME ……………… AGE ……………… TODAY’S
ARRIVAL AND DISMISSAL ROUTINES 20192020 CHILD’S NAME GRADE TEACHER’S
AUDITORY SKILLS CHECKLIST CHILD’S NAME BIRTH DATE PERSON REVIEWING

Child Functional Outcomes

Child’s Last Name

     

Child’s First Name

     

MI

     

DOB

     

IFSP Start Date

     

A Child Measurable/Functional Outcome must identify the skill or behavior we want a child to demonstrate; during routines in their day; and include how it will be known when the child has successfully developed the skill or behavior.

Outcome #      

Date

     

Child Outcome Statement: (What skill or behavior do we want your child to demonstrate; during what routine(s) in their day; and how will we know when your child has successfully developed this skill or behavior?)

     

What is happening now?

     

How will NJEIS and your family measure and document ongoing progress toward this child outcome?

Session Notes Developmental Instrument Curriculum Parent Report Other      

During what typically occurring routines are there opportunities for NJEIS & your family to work on this new skill or behavior?

During What Routines

Strategies (Result in progress toward the outcome)

     

     

     

     

     

     

During what typically occurring routines are there opportunities for your family to work together on this new skill or behavior?

During What Routines

Strategies (Result in progress toward the outcome)

     

     

     

     

     

     

How will others in your child’s life assist in your child’s development of this new skill or behavior?

During What Routines

Strategies (Result in progress toward the outcome)

     

     

     

     

     

     

Are there supports that are needed for the child to achieve this skill or behavior that are solely within the scope of practice of a licensed therapist (OT, PT, SLP)? Yes No If yes, explain below.

  1. What supports or strategies are solely within the scope of practice of a licensed therapist (OT, PT, SLP).

     

  1. How the therapist will incorporate their work into the child’s routines with the family/other caregivers.

     

CHILD’S LAST NAME   CHILD’S FIRST NAME  NJEIS CHILD OUTCOME




October 22, 2012 Page 3



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