125 East Bethpage Road ~ Suite 5 ~ Plainview, New York 11803 Tel (516)731-5588 ~ Fax (516)577-9049

First Date of Service

Child Name:
DOB:	NYEIS#
Provider:	OSC :

IFSP Period:	Authorized Start Date:

The first session for this service was conducted with in the 14 days of its authorized date.

Date Conducted:________________________

There has been a delay in providing service within fourteen (14) days of the authorized start date due to:

Family Scheduling Delays

Family Vacation

Rx not obtained

No Family Contact

Parent Requested Delay

Therapist Reassigned

Cancellation by Provider

Cancellation by Parent

Child Illness

Hazardous Weather

Other:__________________________________________________________

Completed by:	Date:

Forward to Jen McKay fax: 516-577-9628

Internal Use Only:

Copy sent to OSC on ____________________________________