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 Name Last Name
OSC Name *

First Name Last Name
OSC Agency *
OSC Phone Number
Please enter a valid phone number.
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) *

Physical Therapy Assistant (PTA) Certified Occupational Therapist (COTA) Speech Pathologist in clinical fellowship year (CFY) A student enrolled in university program in Physical Therapy A student enrolled in university program in Occupational Therapy A student enrolled in university program in Speech Therapy
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. Maintain ongoing involvement in the care provided, and review the need for ongoing services. Regularly observe early intervention services to ensure overall quality, and to ensure parent/caregiver feedback is incorporated into the intervention.
Above observation will be conducted:
Regularly review session notes, quarterly progress notes, and justification for change in frequency, intensity of method of service, and assistive technology request forms. Review the discharge plan 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 *

Clear
Date *

Month Day Year
Date
Should be Empty: