EXAMPLE PROVIDED
BY: Bridges for Families Birth to 3 Program
INTAKE CHECKLIST
Contact the family
within 48 hours (required by law), of the referral (if possible). If you are
unable to reach the family by telephone within about a week send them a letter.
If two attempts to reach the family fail, send a letter with the date after
which you will no longer attempt to contact them.
Initial telephone
call:
- If the referral
was made by someone other than the child's parents identify the referral source
and ask if they are aware of the referral and our Birth to Three program.
- Depending on the
family's understanding of the program the following information may be shared:
- Explaining
the Bridges program, process, possible costs and eligibility.
- Gathering more
information about the family and child.
- Explain the purpose
of the evaluation and schedule if needed. If evaluation(s) have been completed
by another source have them reviewed by appropriate staff to decide if there
is sufficient information to determine eligibility criteria.
- Put evaluation
on the calendar and notify all staff via e-mail, include the evaluation date
and time, evaluators (put date, time and evaluators in subject of e-mail),
child's name, dob, parents, address where evaluation will be, telephone number,
insurance, concerns about the child's development and interpreter if needed.
- Schedule intake
visit (May do telephone intake if appropriate. Remember to get forms signed)
in enough time before the evaluation so you can give the evaluation team background
information before they evaluate the child.
At the initial
visit:
- Explain the Bridges
program, parent and child rights, Parental Cost Share, and evaluation process
(this may be done by going over the contents of the Welcome Packet).
- Get necessary forms
signed (consent to evaluate, HIPPA, and any needed release of information
forms, especially the primary physician). Leave the carbon copies with the
family.
- Explore family's
concerns regarding their child.
- Gather developmental
information using the Developmental History form as a guide.
- If appropriate,
an evaluator could be present at this visit to conduct a developmental screening.
This decision would be made ahead of time but SC, after talking to the family,
can change this decision.
- Besides giving
the family the resource guide in the Welcome Packet further explanation of
specific community resources might be discussed and given at this time based
on the family's situation.
- Answer any family
questions.
After the initial
visit:
- Email office staff
child demographics gathered at the initial visit
- Fill in the child
demographics, the reason for referral and background information. Remember
to fill in the page headers and signature line of service coordinator (name
and telephone number).
- Share the information
regarding the child's development with the evaluation team. This background
information may be given verbally, by e-mail, putting the information in the
areas on the Developmental Report, or getting the Developmental History written
information to the evaluation team. (Be sure the evaluation team knows how
to access this information.)
- Send out completed
Information Release Authorization forms requesting outside information about
the child if needed.
- Reconfirm the evaluation
with the family a few days to a week beforehand, if necessary or requested
by the family.
- After team meeting
where evaluation has been discussed and possible EI dates, service coordinator
will contact the family to schedule EI meeting.