Berks County Initial Paperwork

The first appointment typically involves paperwork and acclimating to the child and family. Please emphasize the purpose and function of Early Intervention to the families, and treatment times and guidelines so they know what to expect. Routines should be discussed, as well as toys/supplies* that can be used during sessions within the home. Treatment is usually carried out in the home setting with siblings present to simulate a natural daily routine.  You may also meet in the community (i.e., at local parks and libraries).  The frequency established is typically 1x week.

Please follow the suggestions in this video link  if you are treating a child in the Daycare setting.  

*You should not take toys into the home.  If you must, please bag up/clean in front of the parents so that they understand this policy is for cleanliness.

Early Intervention is a family-based model (not a medical model).  The ultimate goal for each child is school preparedness.  The State has provided Early Learning Standards to help guide us as providers toward academic success. Early Learning Standards:  Watch this video ( 90 seconds)

Initial Session: All paperwork should be filled out using the fillable forms in Provider Soft. 

Please refer to this video when filling out INITIAL PAPERWORK.

Not sure if you took care of everything at the first session?  See our checklist!

See samples below:

-Permission to Treat: Blank, PT, OT, SLP, SI (Cognition and Language), Feeding - Have the parent sign the Permission to Treat. You sign as the witness. If the case was transferred to you, you must have the parent/caregiver sign a new form specific to you.  If you treat in a daycare, you must obtain the parent’s signature.

-Rx Form: Prescription form (not needed for SI).  The Prescription form must include the Pediatrician’s name, phone number, contact information and if possible the fax number. Please submit this (completed) form in Provider Soft and it will be faxed on your behalf. For Medicaid patients, you must obtain a Prescription prior to beginning services.

-Policies: Review the policy form (found in the Documents Library in Provider Soft, stressing the importance of keeping scheduled appointments and the “No show” rules.  Parents should call in advance to change appointment times or reschedule. A copy of the Policies should be left with the parent, if possible. There is a link at the bottom of the form for the "Acknowledgment of Receipt of Policies"/Email address for Survey. If you treat in a daycare, you can text the parent the Form. CIS Admin will manage sending a survey to the family at an appropriate time.

-Release of Information-Have parents sign the Release of Information form (only if filled out). You sign as the witness. If you treat in a daycare, you must obtain the parent’s signature.  If you have meetings with anyone (other than a parent/caregiver) about the child (C&Y, etc.), you should have this form filled out and signed by the parent/caregiver.

-Family Intake Information- CIS Admin will add this to your electronic file in PS.

-Ounce/ECO- Typically done at the 2nd session if you run out of time. The Ounce is a developmental checklist used to monitor a child’s progress. Directions and forms are on this page.  Use the ECO decision tree for ECO guidance.  Submit the ECO ratings into the fillable form in Provider Soft and send it to Admin. Hierarchy to be filled out is: SI, SLP, OT, PT. In many cases, the Service Coordinator will designate which therapist/teacher needs to fill out these tools on the Service Page in Pelican. The age for the entry Ounce should be the age of the child at the IFSP date.

-Quarterly Progress Reports (to be done at 3-6-9 months after the IFSP date).  The Service Coordinator will contact you to schedule a time to come out and complete the quarterly meeting with you.  Blank Form

-Communication Log: Please document notes right in Provider Soft. All communication and notable events should be documented on the Communication Log.  If an address or phone number for a family changes, please notify Ann and the Service Coordinator and note it in the system (Notes).

Initial Session Information:

1. Discuss your schedule and flexibility with the family.  Follow the IFSP plan (i.e., 4 units weekly).  If you need to stray from the plan, provide sufficient documentation on your communication log. If there is medically fragile child that is hospitalized often or there is a change in a child’s medical diagnosis who might be experiencing regression in development, a team review (in person or by phone/email) needs to be scheduled to review and discuss a modification to the frequency of services.  

• There can be re-scheduled sessions for unforeseen circumstances.  A rescheduled session is defined as a visit that is cancelled, then “made up” in the same week.  So, if you typically see a child on a Monday, you may reschedule for the following Tuesday through Sunday.  

• If a child cancels one week and you have the ability to make up that visit the following week a “make up” visit is warranted.  Please following this protocol when completing a make up visit:

  • •  Let the other providers and the Service Coordinator (SC) working with the child know that you are doing a “make-up” visit the following week

    • Note on the top of the next session note that the parent requested the “make-up” session and utilize the appropriate code for the missed session (printed at the bottom of every session note): CA: Child absent, PA: EI Professional absent, NS: No show, S: Act of Nature.  3) Document the original missed visit in Provider Soft.  Note that it is not essential for a make-up session to occur as our goal is to educate the caregiver on carryover of services through a routines-based family model.

    • If you do need to make-up a session, make it up in full—only under special circumstances should you add extra units to multiple sessions. Do not double up on units during one session knowing that a conflict is approaching (holidays must be made up after the holiday). Contact the SC if the situation requires a change in the plan (need more units, etc.).

    • You must be aware of your authorized plan (per the IFSP) at all times regarding approved units and time frame for services—particularly when there are changes to the plan*.  If the plan does not match what the SC has communicated to you, you must straighten that out right away (please cc Ann and the SC’s supervisor). Until the plan is updated, you should not see the child. Violations of this policy (straying from units, straying from frequency of units, and/or visits outside of service plan time frames) may result in you not getting paid for those sessions. If the plan is correct, please print the Early Intervention Services page for your chart (from the IFSP). *Examples: Increasing from 3 to 4 units, decreasing from 1x a week to 2x a month, a trial period for a requested service request.

2. Create a session note for each visit.  Here are 2 options to create a session note in Provider Soft on your desktop:

• Post a single session (Watch this video for details)

• Populate a session (Watch this video for details)

In each session note be sure to document how you coached the family/child interaction. Complete the entire form (see Session Note Guidance for written details).  Provide families with a copy of that week’s treatment note by downloading a PDF and sharing it with the parent.  Encourage families to call with questions or concerns that they encounter when you are not present.  NEVER have a parent sign a blank session note.  

3. Provide parents with your contact information (phone number, cell phone number, e-mail, etc.) so they can contact you with questions, cancellations, etc.  You can obtain free business cards online at www.vistaprint.com. Your phone number should populate on every session note.

4. Discuss the goals of Early Intervention with the parents (look ahead of time at the goal or goals written just for your discipline as that is your focus).

• Empower and educate the family so they feel confident in carrying over treatment.

• Provide families with as much information and resources as possible.

• Remind families that you have a very limited amount of time with their child, so it is essential for family members to learn strategies to use to promote carryover during daily routine.

• Inform families that treatment in Early Intervention is play therapy because that is how children at this age learn.

• Provide parents with resources (i.e., books, handouts, our website address www.familiesconnectonline.com), etc.) or lend them books to read to promote the best care for their child.  CIS has a library of books that are family friendly which are accessible to you.

5. Review the IFSP/ER for hearing, vision and other screening. Help parents stay on track with their child’s healthcare. Some children may present with personalities/behaviors that raise a red flag to you. Please remember that you can encourage families to speak to their Pediatrician to recommend a Developmental Evaluation in order to help rule out any organic problems. Please do not indicate your opinions about the diagnosis prior to them being given one.

6. You do not need to print the IFSP/ER.  However, you do need access to them in Pelican.

Tips for Case Transfers