Parent Consent for the Use of an Interventionist with a Formal Plan of Supervision

Parent Consent for the Use of an Interventionist with a Formal Plan of Supervision
Child's Name

First NameLast Name
OSC Name

First NameLast Name
OSC Agency
OSC Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Service Provider
Supervisor
Service Provider Agency
Little Angels Center
Service Provider NPI#
Discipline
Authorization Number
Little Angels will provide Early Intervention Services using an interventionist with the following credentials or area of study: (Check one)
The interventionist requires a formal plan of supervision. The plan of supervision has been approved by the NYS Bureau of Early Intervention. Supervision will be provided by an experiences provider licensed by New York State. Under the Plan of Supervision, the supervisor will (check all that apply):

Attend initial session with child, parent/caregiver, and the interventionist to observe the child and family in routine activities, discuss family priorities, set goals in line with functional outcomes developed at the Individualized Family Service Plan (IFSP) meeting, and plan intervention using an approach that will enable the family tosupport the child’s development during routine activities.
Above observation will be conducted:
Other
Details of above "Other"
I, Parent/Guardian Name of Child Name* consent to the provision of the service indicated above by an interventionist working under the Formal Plan of Supervision.
Parent/Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: