Attachment 1: Early Intervention Service Report Guidelines (pdf)

Illinois Department of Human Services
Bureau of Early Intervention

Evaluation and assessment includes initial and ongoing procedures such as tests or observation or review of existing documentation used by appropriate qualified personnel to determine a child's initial and ongoing eligibility and to assist in the development of the Individualized Family Service Plan (IFSP). Upon completion of an evaluation or assessment, a written report of findings is required and must be submitted in the "Early Intervention Evaluation/ Assessment Report Format" to the Child and Family Connections office that is working with the child/family. Providers must complete the entire report prior to submission. Incomplete reports are not acceptable and will be returned to the provider (See example of Evaluation/Assessment Report Format below).

NOTE: Providers must accept evaluations and assessments that have been completed prior to the initial IFSP meeting when beginning direct services. Early Intervention will not pay for the direct service provider to duplicate initial evaluations and assessments.

EXAMPLE, ONLY--EVALUATION/ASSESSMENT REPORT FORMAT

Name:

EI #:

Evaluation/Assessment Date:

Date of Birth:

Age:

Adjusted Age:

Evaluation/Assessment:

  • OT
  • PT
  • DT
  • SLP
  • SW
  • Other

Evaluator:

Service Coordinator:

Child is being observed in

  • home
  • daycare
  • clinic
  • other
  1. Diagnosis/Reason for Referral:
  2. Concerns expressed by parents in regard to their child' s development:
  3. Medical History/Reports:
  4. Behavioral Observation: (description of child during the assessment)
  5. Clinical Observation:
  6. Tests Conducted
    (standardized assessment tools) Score Age Equivalent Percent of Delay
    Blank Blank Blank Blank
  7. Clinical Narrative of Developmental Domains Evaluated (should address typical/atypical development, specific areas of concern, functional skills & strengths, etc.)
  8. Further assessments recommended: (including assistive technology, family training, health consultation, diagnostic services, nursing, nutrition, psychological, and vision/hearing screening)
    (please state reason)

(For A through H use additional pages as necessary)

RESULTS/IMPLICATIONS:

Based on EI criteria, this child may be eligible for Early Intervention Services in the State of Illinois due to: (please check one)

  • diagnosis of qualifying medical condition
  • 30% or more delay in one or more area of development
  • At risk for developmental delay due to 3 or more qualifying risk factors as stated by DHS.
  • Further assessments/evaluations are needed in order to determine eligibility.
  • This child has not met the eligibility criteria for Early Intervention services in Illinois.

Recommendations for areas that intervention is needed: (please mark all that apply)

  • cognitive development
  • physical development, including vision and hearing
  • language, speech and communication development
  • social-emotional development
  • adaptive self-help skills development

RECOMMENDATIONS FOR GOALS, OUTCOMES, & STRATEGIES FOR SERVICES, WITH FREQUENCY, INTENSITY, AND DURATION WILL BE DETERMINED AT THE IFSP MEETING IN COLLABORATION WITH THE CHILD'S FAMILY BASED ON THEIR IDENTIFIED PRIORITIES.

Evaluator Signature

Date

Printed Name

Phone Number

NOTES:

  • Bill for evaluation/assessment report writing time using the evaluation/assessment code identified under your credentialed/enrolled profession.
  • Bill for the time to write direct service reports which require no testing procedure using the IFSP Development code identified under your credentialed / enrolled profession.