Professional Forms & Resources

General Documents

• EIP Referral Form: (English | Instructions)
• EI Agencies Contact Info (updated 02/19/2010): (PDF | Excel)
• Your Rights in Early Intervention
• Letter from Assistant Commissioner
• NYC Early Intervention Policy and Procedure Manual
• Assistive Technology Specification Form
• New York City Billable AND Non-Billable Service Coordination Activities:
  • After Referral (ISC)
  • Evaluation Process (ISC)
  • IFSP Process (ISC)
  • Post-IFSP Meeting (OSC)

Initial Service Coordination

• EIP A Parent’s Guide: English | Spanish
• Citywide – Languages for Service Coordination
• Initial Service Coordination Package
  • Parental Consent to Initiate Service Coordination | Spanish (Read-Only)
  • Parental Consent to Release/Obtain Information | Spanish (Read-Only)
  • Parental Consent to Use E-mail to Exchange Personally Identifiable Information | Spanish
  • Family Information Form | Instructions
  • Insurance Information (Page 1 Only | Page 2 Only | Instructions)
  • Parent Refusal to Provide Insurance Information | Instructions
  • Child Information Change Form
  • Change in Service Coordinator
  • Request for Additional Evaluation
  • LNS Referral for Evaluation
  • NYCHHC HIPAA Authorization to Disclose Health Information
  • Child & Adolescent Health Examination Form
  • Closure Form | Instructions
• Request for Additional Time/Units for Initial Service Coordination (Bronx Only)

Ongoing Service Coordination

• Request for Prescription for Services
• Prescription for Therapy Services Form
• Status of Start Date of Services Form
• LNS Paperwork Submission Cover Sheet
• LNS Document Request Form
• Change in Service(s)/Service Provider/Service Coordinator
• Parental Consent to Release/Obtain Information | Spanish (Read-Only)
• Parental Consent to Use E-mail to Exchange Personally Identifiable Information | Spanish
• Child Information Change Form
• Closure Form | Instructions

Foster Care Documents

• Foster Care Package
  • Steps Taken to Determine Need for Surrogate Parent for Children in Foster Care
  • Foster Care Letter Part I
  • Foster Care Letter Part II
  • Surrogate Parent Designation by Parent | Spanish (Read-Only)
  • Assignment or Termination of Surrogacy by EIOD

Individualized Family Service Plan – IFSP

• IFSP Package: (Normal* | With Transportation* | Instructions)
  • Page 1: Identifying Information
  • Page 2: Current Development
  • Page 3: Daily Routines
  • Page 4: Functional Outcomes
  • Page 5: Service Plan
    • Page 5A: Service Authorization Form | Codes
    • Page 5B: Co-Visit
  • Page 6: Transportation/AT/Respite
    • AT Device Data Entry Form
    • Transportation Data Entry Form
  • Page 7: SC Activities
    • Page 7A:Transition Plan
    • Page 7B: Transition Plan
  • Page 8: Attestations, Consent for Services
  • Parental Consent to Release/Obtain Information | Spanish (Read-Only)
  • Request for Additional Evaluation
• IFSP Meeting Request/Confirmation Form:
  • Bronx | Manhattan | Brooklyn | Queens | Staten Island

*please note: you will have to print out your own additonal page 5A Worksheets if working with more than one provider.

EIP Services

• Citywide – Languages for Services: PDF | Word
• Status of Start Date of Services Form: PDF | Word
• Justification for Change in Frequency, Intensity or Method of Services (Instructions): PDF | Word
• Make-Up Session Policies and Procedures: PDF | Word
• Make-up Policy – Information for Families (English | Spanish)
• Services Invoice: PDF l Excel
• Notice of Gap in Services Form:  PDF | Word
• NYC EIP Progress Note 9.2014 : PDF | Word
• NYC EIP Session Note Final 10.2015 V1: PDF | Word
• NYC EIP Session Note Final 10.2015 V2: PDF | Word
• Justification for Additional Evaluations: Word l PDF
• Parent Welcome Letter: PDF | Word
• Consent to Email: PDF | Word
• LNS Incident report: Word l PDF
• DOE Waiver: PDF | Word

EIP Evaluations

• Citywide – Languages for Core and Supplemental Evaluation
• LNS Referral for Evaluations
• Parental Consent to Evaluate | Spanish (Read-Only)
• Parental Consent to Release/Obtain Information | Spanish (Read-Only)
• NYC Reason for Delayed Submission of Evaluation | Spanish (Read-Only) | Instructions

CPSE – Committee on Preschool Special Education

• CPSE Parent Guide: (English | Spanish)
• The Transition from EI to CPSE An Overview for Families: (English | Spanish)
• NYS Approved Preschools (Updated February 2006)
• CPSE Administrator Directory
• CPSE Package
  • Steps Taken to Support Transition
  • CPSE Transition Planning and Consent Form
  • Consent for CPSE Notification
  • Referral to the CPSE
  • DEP-1: Determination of Eligibility for Preschool Special Education Services
• CPSE Foster Care Letter
• CPSE School & District Locator

Additional Resources

• New York Early Intervention Offices
  • NYS EI Website
  • NYC EI Website
  • NYC Department of Education
  • NYC Department of Health
  • Westchester County EI Website
• The Office of Health Insurance Services (OHIS) Referral Forms
  • Bronx | Manhattan | Brooklyn | Queens | Staten Island
• Developmental Milestones
• NYC Free Health Clinics
• Human Resources Administration
  • Care at Home | M-11Q Application Form
  • Public Health Insurance
  • Food Stamps & Food Programs