ERIE COUNTY EARLY INTERVENTION PROGRAM

IFSP REVIEW: QUARTERLY REPORT / AMENDMENT REQUEST - PART 1

QUARTERLY REPORT:
March June September December / AMENDMENT REQUEST: (Part 2 must also be completed)
For existing service For new service Supplemental eval. request

Complete the following for an existing service only. ALWAYS complete the name of the Ongoing Service Coordinator.

CHILD'S NAME: DOB:
1. Service: Frequency: ______ Basic Extended Setting:
Service Coordinator: OGSC Agency: Phone:
2. Confirmed Diagnosis: ______CA: CCA (if applicable): ______
CURRENTLY demonstrating skills at ______
3. PROGRESS REPORT:
▪ FOR AMENDMENT REQUESTS please describe the skills the child currently displays.
▪ FOR QUARTERLY REPORTS please include: (A) Number of completed sessions, outlining dates services were rendered,
(B) Reasons any sessions were missed, (C) Comments on parental concerns, (D) Various treatment implementations performed
throughout the quarter, E) Progress made toward all IFSP goals.

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4. PARENT INVOLVEMENT: List specific strategies currently being implemented to involve parents/caregivers and describe carryover
efforts, and comment on the status of such.
5. PLAN: ▪ FOR AMENDMENT REQUEST: Skip to number 6 and then complete Part 2.
▪ FOR QUARTERLY REPORTS: List all treatment implementations including parent involvement/training for the next quarter.
List any recommended changes. (If your recommended changes involve a change in frequency, duration and /or location
of service or they include a recommended additional service, COMPLETE PART 2).
If applicable, other factors that could be inhibiting progress: Behavior Poor attendance Regression between sessions
Setting Carryover Health of child Other: ______
6.  A child this age is typically able to: (Complete this section for amendment requests ONLY, and go to Part 2.)
Was this information shared with the family/team? Yes No Was the family in agreement with any requested changes? Yes No
SIGNATURES:
Printed name and title of Team member: Phone:
Team member signature:______Agency Name: Beyond Boundaries Date:
Printed name and title of Supervisor: ______Phone: ______
Supervisor Signature: ______Date: ______

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