Little Angels Center, Inc. - 235 Blue Point Avenue - Blue Point, NY 11715

(631) 363-5794 Fax (631) 363-8046

Early Intervention Program - Provider and Family Agreement for Home and Center-Based Services

Developed by the Suffolk County LEICC Quality Assurance Subcommittee - Professional Ethics Subcommittee

As a provider of services to children in your municipality Early Intervention Program, I am bound by a Code of Professional Ethics. It is important that the families of the children I provide services understand the professional standards that are incorporated in this code and that we enter into an agreement to assure that the standards are followed.

I will:

• Provide services to the best of my ability based upon my training and credentials:
• Maintain all information to protect the privacy of your child and family;
• Make every effort to follow the schedule for service provisions;
• Advise you ahead of time if I am going to be absent for an extended period of time and call ahead of time if sickness prevents me from providing a daily service;
• Maintain accurate records of the services provided and bill only for those services provided;
• Not accept cell phone calls while providing services;
• Work cooperatively with other members of the treatment team;
• Work with you and other family members towards developing strategies you can use to enhance your child’s development.

Please Understand and Comply with the following professional boundaries:

• I am not allowed to work for you in any capacity other than to provide therapy to your child as authorized on the IFSP.
• I am not allowed to be left alone with your child.  A person over the age of 18 must be available in the home at the time I provide services.
• I am not allowed to transport you or your child anywhere or at anytime.
• Our relationship is a professional one.  It is not appropriate for me to accept gifts or meals and it is not appropriate for me to be involved with you in personal activities such as birthday parties or family events.
• I am legally obligated to report any suspicion of neglect or abuse of the child.  

I have read this agreement and understand the professional boundaries that my therapist is required to follow.