2

Q g

JUST KIDS
Early Childhood Learning Center
Consent for Evaluations
date

Executive Director

Stephen Giwdan Diitcnw Cadi? CiuiEvuio Director of Childimfc Services

foster worker name agency-

child' s name date of birth

-fa/ gfWaddress
De ir fllS. S
foster Corker's name

listrict

We have received consent from the school district to evtluate the above-mentioned child at our facility. Please si .jn the enclosed consents for the individualized evaluations an I fax-return to 924-4298. In addition, as the foster parent/guardian will be br. nging the child in for the evaluations, please sign those st; tements below with which you agree: I hereby give consent for the above referenced child's foster parent(s)/guardian(s) to be present for and participate in the child's evaluation at Just Kids. "
Middle Island Longwnod Road P.O. Bos 12 Middle Island, NY M9S3 (63D924-OOOB Phone (63 1)924-1X43 Fax Lindenhurst 887 KeJJum Strtet

A^L^A-^IJ^
I hereby give consent for the above referenced c h i l d ' s fos;er p a r e n t ( s ) / g u a r d i a n ( s ) to receive a copy of the child's eva Luations.
Foster Work/Legal Guardian

11757 (631 (884-3000 Phone (631) 884-1959 Fax

Riverhead $56 East Main Street Rivemead, NY 11901 (631) 369-1927 Phone (631)369-1937 Fax William Floyd 99 Lexington Roud Shirley, NY 11967 (631) 231-6800 Phone (631) 281-6096 Fax

I do not give consent for the above referenced c h i l d ' s fos .er parents; (s)/guardian (s) to be present for and par icipate in the child's evaluation at Just Kids.
(fos er.con) Foscer Worker/Legal Guardian

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Service/Support None Required

Service/Support None Required

ilPartlcipatiott witb Age App^piriate.Peejissioccuirs only whence rt4ttaipe.iirsey^tity;.bfttie disability is suchtliat, even, with the

'

''

Explanation of the extent, if any, to.vhich the student will not participate in general education programs, including extra curriculac and other nonacadcrnic activities! In die areas of non-participation, the^student requires special instruction in an environment with a smaller student-to-teacher ratio and minimal distractions in order to progress in achieving the learning standards,

Current functioning and individual needs in consideration of: the results of the initial or most recent evaluation, the student's strengths, the concerns of the parents; the student's needs related to communication, behavior, use of Braille., assistive technology, limited English proficiency; and how the student's disability affects participation in appropriate activities.

fiofr the Student's Disability Affects InvolVement and Projpsss PaMdpMoiti in Age Appropriate Activities;
The student has a significant delay in speech skills and concept development, which interferes with participation in age appropriate activities. Academic Achtevenietit, $uflcti^ Current levels of knowledge and development in subject and skill areas, including activities of daily living, level of intellectual functioning, adaptive behavior, expected rate of progress in acquiring skills and information and learning style. Levels/Abilities Winona exhibits a significant delay in speech and language skills at this time. Winona is exhibiting delays in her nonverbal and verbal reasoning skills as well as in her general concept development Winona continues to have difficulty identifying colors and does not yet recognize letters of the alphabet. Needs Winona needs to improve overall speech and language skills. Winona needs to develop her cognitive and academic skills. Standardized Test fcwultSi Pate Test 11 /06V2009 Peabody Developmental Motor Scales-2 Test <)f Visual-Motor Skills 11/03/2009 Achenbach Child Behavior Checklist Goldman Fristoc 2 Khan-Lewis Phonological Analysis Preschool Language Scale - 4

SubTest Fine Motor Quotient

Score/Type 88

Total
Parent Teacher Speech Articulation Composite Score Auditory Comprehension Expressive Communication Total Language Score Communication Domain Daily Living Skills Domain Socialization Domain Motor Skills Domain Adaptive Behavior Composite

<5S
54/TS 67TS 60 49 65 64 61 65 77 79 81 72 page 2 ofS

Vineland Adaptive Behavior Scalesilnterview Ed.

mnonaRPixcitellt

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Wechsler Preschool & Primary Scales of Intell.-III

Verbal Performance Full Scale

67 73 69

The degree and quality of the student's relationships with peers and adults, feelings about self and social adjustment to school and community environments. Levels/Abilities Wjnona presents with attentiona). difficulties and tendencies toward aggressive behavior. In the classroom, Winona requires a fair amount of adult redirection in order to follow instructions and cairyout assigned tasks. Needs Winona needs to improve her relationships with peers and adults. She needs to develop her ability to follow instructions and attend to tasks.

Physical Development:
The degree or quality, of the student's motor and sensory development, health, vitality and physical skills or limitations that pertain to the learning process. Levels/Abilities Winona's physical levels and abilities are within age appropriate expectations. Needs There are no physical or motor needs that should be addressed through special education, at this time.

Management:Needs; '

. ' ::.-."."

'_:-":' !. . ; ' : . ' :': ;:'v . ' ..'". '.

The nature of and degree to which environment modifications and human or material resources are required to enable the student to benefit frorn. instruction. Management needs arc determined in accordance with the factors identified in the areas of academic achievement, functional performance and learning characteristics, social, development and physical development, The student has significant delays and requires an intensive, small teacher-to-studcnt ratio program provided in a special school environment in order to academically progress.

Committee: Committee on Preschool Special Education Date: 11/20/2009 Reason: Initial Eligibility Determination Meeting Expected Grade: Preschool Attendance: BrendaMcCabe, Chairperson; TomSipala, General Education Teacher; Ira Siegel, County Representative; Barbara Gramello, Special Education Teacher; Brenda McCabe, Speech/Language Therapist; Lisa Carbone, Foster Mother; Paul Piscitelli, Additional Parent Member; Lori Goldstein, Facility Representative; Lori Townes, Case Manager Comments: Current reports indicate that this student presently attending a preschool setting five full days weekly, demonstrates average daily living skills. The student is living in a foster home at (his time however, the father is pursuing full custody. The evaluation process was initiated by the foster parent and Department of Social Services due to concerns with learning and language skills. The testing revealed significant delays with expressive and receptive language skills. Further, delays with concept development impact overall learning. It is felt that the student is eligible for special education services. Recommendation, is for classification as a Preschooler With A Disability and placement in an 18:2:1 roll day special class with speech three times individually. The foster parent, father, and DSS Caseworker are in agreement. Based Upon: Social History, 11/20/2009
Psychological. Evaluation, 11/03/2009 Speech/Language Evaluation, 11/03/2009 . ' ' !'.[ .? ':
Reasons for Rejection

Other Options Considered

Wintjna K Piscitelli

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The Cornrmttee considered a general education setting with support services such as related services and. consultation services. The Committee considered a special class program.

This option was rejected because Winona's current language processing needs indicate that a more intensive setting with support is needed to address the needs. This option was rejected because it would be overly restrictive and Winona's needs could be met in a less restrictive
environment.

Identify when periodic reports on the progress the student is making toward meeting the annual goals will be provided to the student's parents:

Manner: Written Report?

Frequency: 4 limes during (he school year.

'GOALS. * For students with severe disabilities who would meet the eligibility criteria to take the New York State Alternate Assessment, the IEP must also include short term instructional objectives and benchmarks for each annual goal. Annual Goal: What the student will be expected to be able to do by the end of the year in which the IEP is hi effect. Evaluation Criteria: How well and over what period of time the student must demonstrate performance hi order to consider the annual goal to have been met. Procedures to Evaluate Goal: The method that will be used to measure progress and determine if the student has met the annual goal. Evaluation Schedule: The dates or intervals of time by which evaluation procedures will be used to measure the student's progress.
SPEECH / LANGUAGE Annual Goal

1. Winona will produce 6 target sounds in isolation, syllables, all position of words, and blends during the therapy session. Evaluation Criteria: 80% success, over 4 weeks Procedure to Evaluate Goal; Recorded observations Evaluation Schedule; By the next IEP Annual Review date Primary Responsibility: Speech/Language Therapist
1. Winona will produce 2 target sounds in isolation, syllables, all position of words, and blends during the therapy session.

Criteria: 80% success, over 4 weeks Schedule/By: quarterly

2. Winona will produce 4 target sounds in isolation, syllables, all position of words, and blends during the therapy session.

Criteria: 80% success, over 4 weeks Schedule/By: quarterly Annual Goal 2. Winona will eliminate the use of phonological processes (e.g., deletion of final consonants, initial voicing, syllable reduction, and stopping). Evaluation Criteria: 80% success, over 4 weeks Procedure to Evaluate Goal: Recorded observations Evaluation Schedule: By the next IEP Annual Review date Primary Responsibility: Speech/Language Therapist
1. Winona will eliminate the use of phonological processes (c.g,, deletion of final consonants, initial voicing, syllable reduction, and stopping).

Criteria: 80% success, over 4 weeks

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Schedule/By: quarterly 2. Winona wf U eliminate the use of phonological processes (e.g., deletion of final consonants, initial voicing, syllable reduction, and stopping). Criteria: 80% success, over 4 weeks Schedule/By: quarterly Annual Goal 3. Winona will respond to a simple "Wh" question asked by a therapist, using at least 5 words per utterance, Evaluation Criteria: 80% success, over 4 weeks Procedure to Evaluate Goal: Recorded observations Evaluation Schedule: By the next IEP Annual Review date Primary Responsibility: Speech/Language Therapist 1. Winona will respond to a simple "Wh" question asked by a therapist, using at least 3 words per utterance. Criteria: 80% success, over 4 weeks Schedule/By; quarterly 2. Winona will respond to a simple "Wh" question asked by a therapist, using at least 4 words per utterance. Criteria: 80% success, over 4 weeks Schedule/By: quarterly Annual Goal 4. Winona will identify and use basic and linguistic concepts (e.g., small/large, either, first/last) by pointing to or labeling pictures. Evaluation Criteria: 80% success, over 4 weeks Procedure to Evaluate Goal: Recorded observations . Evaluation Schedule: By the next IEP Annual Review date Primary Responsibility: Speech/Language Therapist 1. Winona will identify and use basic and linguistic concepts (e.g., small/large, either, first/last) by pointing to or labeling pictures. Criteria: 60% success, over 4 weeks Schedule/By: quarterly 2. Winona will identify and use basic and linguistic concepts (e.g., small/large, either, first/last) by pointing to or labeling pictures. Criteria: 70% success, over 4 weeks Schedule/By: quarterly Annual Goal 5. Winona will follow 6 multi-step directions presented orally (e.g.. point to the big car before pointing to the red bicycle) incorporating basic and linguistic language. Evaluation Criteria: 80% success, over 4 weeks Procedure to Evaluate Goal: Recorded observations Evaluation Schedule: By the next IEP Annual Review date Primary Responsibility: Speech/Languae Therapist 1. Winona will follow 2 multi-step directions presented orally (e.g.. point to the big car before pointing to the red bicycle) incorporating basic and linguistic language. Criteria: 80% success, over 4 weeks Scb.edu.le/By: quarterly
2.

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Winona will follow 4 multi-step directions presented orally (e.g., point to the big car before pointing to the red bicycle) incorporating basic and linguistic language. Criteria: 80% success, over 4 weeks Schedule/By: quarterly Annual Gnal 6. Winona will comprehend and use correct nouns (e.g., regular and irregular) and verb tense (e.g., present progressive, regular past tense, irregular past tense). Evaluation Criteria: 80% success, over 4 weeks Procedure to Evaluate Goal: Recorded observations Evaluation Schedule: By the next IEP Annual Review date Primary Responsibility: Speech/Language Therapist 1. Winona will comprehend and use correct nouns (e.g.. regular and irregular) and verb tense (e.g., present progressive, regular past tense, irregular past tense). Criteria; 60% success, over 4 weeks Schedule/By: quarterly 2. Winona will comprehend and use correct nouns (e.g., regular and irregular) and verb tense (e.g., present progressive, regular past tense, irregular past tense). Criteria: 70% success, over 4 weeks Schedule/By: quarterly SOCIAL / EMOTIONAL / BEHAVIORAL AnaaaLGoal 7. Winona will display the ability to play cooperatively, take turns, and sbare materials without inappropriately displaying frustration. Evaluation Criteria: 80% success, over 4 weeks Procedure to Evaluate Goal: Recorded observations Evaluation Schedule; By June Primary Responsibility: Special Education Teacher 1. Winona will display the ability to play cooperatively, take turns, and share materials without inappropriately displaying frustration. Criteria: 60% success, over 4 weeks Schedule/By; quarterly 2. Winona will display the ability to play cooperatively, take turns, and share materials without inappropriately displaying frustration. Criteria: 70% success, over 4 weeks Schedule/By; quarterly Annual Goal 8. Winona will correctly follow the classroom morning routine (e.g., unpack own backpack, put away personal belongings and school materials, join in circle time, independently work on seat-time activity). Evaluation Criteria: 80% success, over 10 weeks Procedure to Evaluate Goal: Recorded observations Evaluation Schedule: By the middle of June Primary Responsibility: Special Education Teacher 1. Winona will correctly follow the classroom morning routine (e.g., unpack own backpack, put away personal belongings and school materials, join in circle time, independently work on seat-time activity). Criteria: 80% success, over 10 weeks Schedule/By: By the middle of June

K Pisciteili

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Annual Goal 9. Winona will transition appropriately (e.g,, willingly prepare for next activity, refrain from tantrums, appropriately express disappointment when experienced) from classroom to special subject areas. Evaluation Criteria; 80% success, over 4 weeks Procedure to Evaluate Goal: Recorded observations Evaluation. Schedule: By June Primary Responsibility: Special Education Teacher 1. Winona will transition appropriately (e.g., willingly prepare for next activity, refrain from tantrums, appropriately express disappointment when experienced) from classroom to special subject areas. Criteria: 60% success, over 4 weeks Schedule/By: quarterly 2. Winona will transition appropriately (e.g., willingly prepare for next activity, refrain from tantrums, appropriately express disappointment when experienced) from classroom to special subject areas. Criteria; 70% success, over 4 weeks Schedule/By: quarterly Annual Goal 10. Winona will remain on task during the class lessons (e.g. student will appear to focus attention on presented materials, will refrain from engaging in distracting social interactions). Evaluation Criteria: 80% success, over 4 weeks Procedure to Evaluate Goal: Recorded observations Evaluation Schedule: By June Pranary Responsibility: Special Education Teacher 1. Winona will remain on task during the class lessons (e.g. student will appear to focus attention on presented materials, will refrain from engaging in distracting social interactions). Criteria: 60% success, over 4 weeks Schedule/By: quarterly

r 2. Winona will remain on task during the class lessons (e.g. student will appear to focus attention on presented materials, will refrain from engaging in distracting social interactions). Criteria: 70% success, over 4 weeks Schedule/By: quarterly
BASIC COGNITIVE / DAILY LIVING SKILLS Annual Goal 11. Winona will identify at least 10 printed letters of the alphabet.

Evaluation Criteria: 70% success, over 4 weeks Procedure to Evaluate Goal: Classroom tests Evaluation Schedule: By June Primary Responsibility: Special Education Teacher
1. Winona will identify at least 10 printed letters of the alphabet. Criteria: 50% success, over 4 weeks Schedule/By: quarterly 2. Winona will identify at least 10 printed letters of the alphabet. Criteria: 60% success, over 4 weeks Schedule/By: quarterly Annual Goal

Winona R Pisdlelli

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12. When presented with different colors on cards, Winona will identify 10 bask colors. Evaluation Criteria: 80% success, over 4 weeks Procedure to Evaluate Goal: Classroom tests Evaluation Schedule: By June Primary Responsibility: Special Education Teacher 1. When presented with different colors on cards, Winona will identify 4 basic colors. Criteria; 80% success, over 4 weeks Schedule/By: quarterly

2. When presented with different colors on cards, Winona will identify 8 basic colors.
Criteria: 80% success, over 4 weeks Schedule/By; quarterly Annual Goal 13. Winona will sort, group and classify 4 objects. Evaluation Criteria: 80% success, over 4 weeks Procedure to Evaluate Goal: Classroom tests Evaluation Schedule: By June Primary Responsibility: Special Education Teacher 1, Winona will sort, group and classify 2 objects. Criteria: 80% success, over 4 weeks Schedule/By: quarterly 2. Winona will sort, group and classify 4 objects. Criteria: 80% success, over 4 weeks Schedule/By: quarterly Annual Goal 14. Winona will reproduce three-dimensional block designs from a model. Evaluation Criteria: 80% success, over 4 weeks Procedure to Evaluate Goal: Classroom tests Evaluation Schedule: By June Primaiy Responsibility: Special Education Teacher 1. Winona will reproduce three-dimensional block designs from a model. Criteria: 60% success, over 4 weeks ScheduJe/By: quarterly 2. Winona will reproduce three-dimensional block designs from a model. Criteria: 70% success, over 4 weeks Schedule/By: quarterly

Winona R Piscittslli

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l/

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tti

JUST KIDS
Early Childhood Learning Center
Structured Observation Date: 11/17/09 Time: 9:05-9:45 am

BJ

Sieve Held Executive Director Stephen Gordon Director C*thy Cunfanno Director of Children's Services

yName: Winona Piscitelli I D.O.B.: 7/06/05 Observer: Patricia Walter, M.S.

Winona currently attends ^pHBBi Preschool five days a week. There were 15 children and 2 adults present during this observation. Winona was playing with two peers in the housekeeping area when the observer arrived. She was noted to verbalize during imaginative play and use toys in a functional manner. When one of her peers asked her to get a plate (since they were cutting up a pizza pie) Winona retrieved a spoon and brought it back to the table. Her peer said, "No, a plate!" and Winona then picked up a measuring cup to show. The other child picked up a plate, showed Winona and said, "This is a plate!" Winona smiled and nodded. Several minutes later, Winona noticed the observer. She ran up and hugged the unfamiliar person. Winona stated her name when asked and briefly showed interest in the conversations of other children and the observer. She then scribbled briefly on the chalk board and returned to the observer to show a piece of broken chalk. Next, Winona skipped around the classroom and briefly stopped to watch a child complete an art activity with an adult. The adult asked Winona if she had already had a turn to make a turkey and Winona nodded her head in agreement. When Ms. Nicki, Winona's teacher, announced that it was time to clean up the toys Winona continued to skip around the room until her individual name was called. Her teacher asked her to help put away the toys in the housekeeping area. Winona walked to the housekeeping area and hid behind the refrigerator. She did not follow the teacher's verbal directives but eventually responded when visual cues were present. (Her teacher handed her a basket with a photograph of food items that belonged in the container.) Winona placed several items appropriately in the basket and then began to skip and hop around the room. She laughed and nodded her head "no" when continuously told to put the toys away. Her teacher explained to Winona that she would have to 'sit out' if she didn't help clean up. After running and laughing, Winona was walked to a chair with physical [prompting. Her teacher sat with her and explained that she needed to help her class. 'hen Winona stated she was ready to help, the teacher told her to put a specific toy away. Winona followed through and placed it where it belonged. Winona then joined the children on the carpeted area. She held hands with her peer as they sang a "Hello" song and sat down when told. As Winona listened to a short story she was noted to chew on her right thumb. She attempted to sing along with the songs and participate in non-verbal tasks although she did not appear to know the words to the familiar preschool songs. Winona ecognized her name in print, with prompting. She attempted to spell her name as the eacher pointed to the letters; however, she named various letters randomly. When some of the children left the room to use the bathroom, Winona and several peers remained to

Middle Island Long wood Road

P.O. Box 12
Middle Island, NY

11953
(631)924-0008 Phone (631) 924-1243 Fax Lindcnhurst 887 Kellum Street Lindenhurst, NY

11757
(631) 884-3000 Phone (631) 884-1959 Fax Riverhead 556 East Main Street Riverhead, NY 11901 (631)369-1927 Phone (631)369-1957 Fax William Floyd 99 Lexington Road Shirley, NY 11967 (631) 281-6800 Phone (631) 281-6096 Fax

Winona Piscitelli

Structured Observation

Page 2

play Simon Says. She seemed to have difficulty identifying many of her body parts and relied on the visual cues of others to follow through. According to Ms. Nicki, Winona's teacher, the behaviors observed were typical. Winona reportedly enjoys participating in classroom activities. Winona will attempt to sing songs and engage in motor tasks with her peers. She has a difficult time following directions and demonstrates poor conceptual knowledge of basic skills.

Patricia Walter, M.S. Special Education Teacher

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i Central School District Committee on Preschool Special Education Office of Special Education

Agency Invitation for Committee on Preschool Special Education Meeting November 10,2009

Re; Winona PisatelH Dear: The parent or guardian of the above named child has been invited as a member to attend the meeting of the Committee oir Preschool Special Education. The Committee is inviting an appropriate representative from your agency to attend. Please note the date, time and place of the meeting so that the necessary arrangements may be made to attend. The meeting is scheduled for: Date: 11/20/2009 Time: 09:00 AM Place: Special Education Office Purpose: Initial Eligibility Determination Meeting

If you have any questions, please do not hesitate to call. So that we may plan accordingly, please contact our office to confirm the attendance of a representative from YDUT agency. Thank you for your cooperation in this regard. ' ^ **^

Sincerely, JuliMulcahy
MtMulcahy Coordinator of Pre-K & Elementary Special Ed,

Cam-Held Enterprises, Inc..

aa^tj^m^i^^tt^ffffl^gjg^g^f^t^^^^g

Maiimg Address: P.O. Box 12 e Middle Island New Yoik 1 1953 Dear CPSE Chairperson: Enclosed is the e v a l u a t i o n packet for The evaluation packet includes the following: Date
6 f 0 9 f % 0 9 Preschool Summary Social History Structured Observation Psychological Evaluation Speech/language Evaluation Occupational Therapy Evaluation Physical Therapy Evaluation Audiological / /^ * /1/)? ///<3/0/r / / '/ * j """-'<* .' x -^ r j y >, ^ '-*" O *****; o
:

0" Educational Evaluation 0 0 0 9 0 Vision Evaluation Birth Certificate Physical Examination* Immunization record Child/Preschool Outcome Summary Form

If you have any questions, I can be reached at 924-0008, ext. 208. The CPSE meeting is important. I hope you can attend.

'' "

Robin Richman, MS.Ed. Evaluation Coordinator enc.sen

Cam-Held Enterprises, Inc.

Longwood Road Middle Island o. New York o (631) 924-0008 Mailing Address: P.O. Box 12 o Middle Island New York 11953

Dear P a r e n t ( s ) / G u a r d i a n ( s ) Enclosed is the evaluation packet for Your evaluation packet includes the following:
6 @ $ f f> 0 8 0 0 9 S> ) 9 Preschool Summary - (a summary of each evaluation) Social History . Psychological Evaluation Speech/language Evaluation Occupational Therapy Evaluation . . .- . . Physical Therapy Evaluation . ...-..~ Audiological . Educational Evaluation Vision Evaluation Birth C e r t i f i c a t e Physical Examination* Immunization record Child/Preschool Outcome Summary Form (to be discussed at CPSE)

*Please note that if this is an initial evaluation, and the physical examination is not included in the packet, or the school district has not been provided a copy, the Committee on Preschool Special Education (CPSE) meeting may be cancelled. Please review these evaluations and contact me if there are any questions about the reports so that they can be discussed prior to the CPSE meeting. Your school district will contact you regarding the date of the CPSE meeting. The recommendations on the reports are' only recommendations, and final eligibility and determination of frequency and location of services will be made at the CPSE meeting. Possibilities of location may include-. in at at in your home a therapeutic center (i.e., Just Kids, NIS, Alternatives) preschool or day care a baby sitter's home The CPSE meeting is

I can be reached at 924-1000, ext. 208. important. I hope you can attend.

Robin. Richman, MS . Ed . Evaluation Coordinator enc.let

UJ

JUST KIDS
Early Childhood Learning Center
Preschool Student Evaluation Summary Report
STUDENT: Winona Piscitelli
EVALUATION DATES: 11/3/09- 11/6/09 AGENCY: Just Kids Learning Center CONTACT PERSON: Robin Richman PHONE: 924-0008

3 U)
X
Steve Hdd Executive Director Stephen Gordon Director Cathy Cianfaruio Director of Children's Services

DATE OF BIRTH: 7/6/2005 FOSTER PARENT(S)J LEGAL GUARDIAN: Lori Towns RELATIONSHIP: DSS Caseworker ADDRESS: P.O. Box 18100, Hauppauge COUNTY OF RESIDENCE: Suffolk

SCHOOL DISTRICT4

CURRENT LEVEL OF SERVICES: None; attends preschool

This report is a summary of the findings of the evaluation which includes a detailed statement of the child's individual strengths and needs. It indicates the individually administered evaluation measures used, including the result of the observation of the child and the findings pertinent to the suspected disability. This summary and the documentation of the evaluation results are transmitted to all members of the Committee on Preschool Education and to the Municipality Representative. The summary is also transmitted to the parent

Cognitive Development: Winona's Full Scale IQ of 69 (2nd percentile) on the WPPSI-III indicates her performance to fall within the Extremely Low range of intelligence and well below normal limits (>-2 Standard Deviations). This Full Scale IQ is comprised of a Borderline range Performance IQ of 73 (4th %ile, -1.7 SD) and an Extremely Low range Verbal IQ of 67 (1 st%ile, >-2 SD). Winona performed within the Low Average to Average range on 2 of the 9 subtests administered; relative strengths were noted in her ability to complete visual patterns (37th %ile) and in her visual processing speed (16th %ile). Scores on the remaining subtests fell at or below the 5th %ile. Although self-directed, Winona responded well to redirection. She appeared motivated, however, she struggled to maintain her focus and concentration. She often repeated the test items back and did not appear to understand what was being asked of her. She required additional teaching trials for most tasks. Social/Emotional Development:
Middle Island Longwood Road P.O. Box 12 Middle Island, NY 11953 (631)924-0008 Phone (631)924-1243 Fax Lindenhurst 887 Kellum Street Lindenhurst, NY 11757 (631) 884-3000 Phone (631) 884-1959 Fax Riverhead 556 East Main Street Riverhead, NY 11901 (631)369-1927 Phone (631)369-1957 Fax William Floyd 99 Lexington Road Shirley, NY 11967 (631) 281-6800 Phone

Winona was removed from her biological mother's care due to neglect and placed in foster care in 9/09; she sees her biological mother weekly. On the Socialization domain of the Vineland-ll, Winona's S.S. of 79 (8th %ile, -1.4 SD) fell within the Below Average range. Winona demonstrates friendship-seeking behavior with others the same age; sometimes responds appropriately when familiar adults make small talk; uses actions, but not yet words to express happiness or concern for others; has difficulty with social boundaries; sometimes plays cooperatively with more than one child; has difficulty with snaring and turn taking; says thank you when given something; sometimes responds appropriately to reasonable changes in routine; sometimes acts appropriately when introduced to strangers; and sometimes says she is sorry after hurting another's feelings. Her foster mother's responses to the Achenbach CBCL revealed that Winona does not present with any significant behavioral concerns, however, she did not concerns regarding Winona's temper tantrum behavior and "meltdowns" (e.g., cries, yells, thrashes). It was also reported that Winona has difficulty transitioning and at times appears to be over-stimulated by the environment. Winona is described as impulsive and hyperactive. She runs and jumps around the house and is rough with others. Her teacher's responses to the Achenbach CTRF yielded a Borderline elevation on the Aggressive Behavior scale and a Clinically Significant elevation on the Attention Problems scale. In the school environment, Winona has great difficulty concentrating; cannot seem to sit still; sometimes has difficulty following

Winona Piscitelli

Preschool Student Evaluation Summary Report

Page 2

directions and carrying out assigned tasks; is often inattentive; sometimes hits or gets into fights with others; is often defiant; and does not seem to feel guilty after misbehaving. Physical Development: Little information is known about Winona's birth and medical history prior to September of 2009. She was treated for burns to her right wrist in 4/09. Since being enrolled in preschool, she has experienced several common colds/illnesses. A recent audiological evaluation revealed normal hearing sensitivity in both ears with normal middle ear function bilaterally. Winona's S.S. of 81 (10th %ile, -1.3 SD) on the Vineland-ll Motor Skills domain indicates her overall motor skills to be in the Below Average range. Winona sometimes walks up and down stairs alternating feet; runs smoothly changing direction and speed; rides a bicycle with training wheels; sometimes catches a beach ball-sized ball from at least 6 feet away; holds a pencil or crayon in the proper position; can draw at least one recognizable form but does not yet make recognizable letters or numbers; has difficulty opening and closing scissors with one hand; sometimes colors simple shapes; and draws a circle freehand while looking at an example. As per the PDMS-2, Winona's fine motor/perceptual skills are within the upper limits of the Below Average range (FMQ of 88, 21st%ile). With the exception of a mild weakness in her grasping skills, Winona exhibits adequate visual motor integration skills. Her cutting with scissors is choppy. Her graphomotor design copy skills are weak (TVMS-R, S.S. 68, 2nd %ile, >-2 SD), however, this may be due to lack of exposure. On the Sensory Profile, Winona's foster mother's responses revealed that Winona presents with some concerns in the areas of touch processing, emotional/social responses, and behavioral outcomes of sensory processing. Language and Communication Development: Results of the PLS-4 indicate that both Winona's ability to understand language (Auditory Comprehension, S.S. 65,1st %ile, >-2 SD) and her ability to use language to communicate (Expressive Communication, S.S. 64, 1st %ile, >-2 SD) are significantly delayed. Receptively, Winona followed two-step directions but had difficulty understanding most age-expected language concepts. Expressively, she answered simple questions, used a variety of nouns, modifiers, and pronouns, and produced basic 4-5 word utterances, but did not answer questions logically or about hypothetical events or complete analogies. Winona's sentence length (MLU) could not be accurately assessed as her speech was significantly compromised by speech sound production errors, particularly in connected utterances. Pragmatic language skills were at the 3-4 year range. As per the GFTA-2 (S.S. 60, 3rd %ile, >-2 SD) and the KLPA-2 (S.S. 49,1st %ile, >-2 SD), both Winona's articulation skills and phonological development, respectively, are well below normal limits. Overall intelligibility is judged to be poor. Winona was 75% intelligible in connected speech when contextual cues were available, and <50% intelligible in unfamiliar situations. Upon informal observation, all oral peripheral structures were symmetrical and had adequate range of motion for speech and vegetative purposes. During the evaluation, Winona presented with a slightly hyponasal quality to her voice that appeared to be the result of nasal congestion. Adaptive Behavior: Self-help skills, as assessed via parent report on the Vineland-ll, fell within the Below Average range (Daily Living Skills, S.S. 77, 6th %ile, -1.5 SD). Winona sometimes performs the following: uses the toilet without help; puts on clothing that opens in the front (does not yet fasten snaps or zip zippers), brushes her teeth without help; clears unbreakable items from her place at the table; puts away personal possessions; is careful when around hot objects; uses the TV or radio without help; demonstrates appropriate behavior while riding in a car; and follows household rules.

Date summary and evaluations sent to the parent, Committee on Preschool Special Education including the Municipality Representative and Suffolk County: ? Jj

u
WJ

JUST KIDS
Early Childhood Learning Center
Social History Summary Date: 11/3/09 Denise Ahlgrim, LMSW

Q ^Name: Winona Piscitelli 5D.O.B.: 7/6/05 i

Steve Held Executive Director Stephen Cordon Director Cathy Cianfarano Director of Children's Service!

Reason for Referral: Winona (Nona) is a 4 year 5 month old white female child who is being referred for this CPSE evaluation at the request of SCDSS foster care worker, Lori Towns, and Winona's foster mother, Lisa Carbone on the consent of the ItfMpMHbSchool District. Information in this report was obtained during a center based interview with Ms.^HfeHftat Just Kids and a phone interview with Ms. Towns. The child's language is English. Ms^HMHfctconcerns fr Winona are in the areas of speech and language development, s and behavior. Winona's speech is described as difficult to understand and Ms.<^dHB&' noj sure ^ g j yy|nona a|ways comprehends what she is told. Times of transition are also said to be difficult for Winona. She will often scream, cry, thrash, and look "overwhelmed." CPS had referred Winona's biological mother to obtain evaluations for her daughter previously, however, evaluations were never obtained. Upon moving to her current foster home, Winona began attending preschool at St. David's in Riverhead. She attends Monday - Friday 8:30-4:30. Winona's medical needs are followed by Dr. Festa. Family History: Winona currently resides with foster mother anni Girl. Winona sees Ms. is relationship is said to be positive for /mona. Winona was placed in the custody of SCDSS on September 16, 2009 and with Ms. on September 23, 2009 after a brief stay at a different foster home. CPS has been providing services for Winona's mother at different times over the past 2 years. Winona and her mother moved from their Nassau County, NY home in 2007. At that time, Winona's father was unable to find them. Winona and her mother have since resided in several counties in New York, as well as in Ohio. Currently, Winona has supervised visits once weekly with her mother. Winona's father is establishing paternity and working to obtain custody of Winona. Winona has one adult brother (21), who is diagnosed with autism and who lives in a residential facility in Northern NYS. Winona's mother's parental rights for him were terminated in 2004. Winona has no contact with her brother. Extended family medical history is reported to include mental retardation, autism, and mental health problems. Winona

Middle Island Longwood Road P.O. Box 12 Middle Island, NY 11953 (631)924-0008 Phone (631)924-1213 Fax Lindcnhurst 887 Kellum Street Lindenhurst, NY

11757
(631) 884-3000 Phone (631) 884-1959 Fax Riverhead 556 East Main Street Riverhead, NY 11901 (631) 369-1927 Phone (631)369-1957 Fax William Floyd 99 Lexington Road Shirley, NY 11967 (631) 281-6800 Phone

Winona Piscitelli Medical History:

Social History Summary

Page 2

Limited information regarding Winona's prenatal, birth, and postnatal histories is available. Winona was born at Nassau County Medical Center. Prior to living in her current foster home, Winona last received routine medical care in 2006. In April 2009, Winona was taken to the emergency room in Richland City, Ohio, due to burns on her right wrist after being injured in a fire pit. She currently has a scar on her wrist. Ms.'Rioted Winona has had multiple illnesses since beginning her first preschool experience, but is otherwise described as healthy. Ms.,aAH|MBis currently looking into bringing Winona to her first dental check-up. Developmental History: No developmental history was able to be obtained from Winona's mother when requested by foster care worker, Lori Towns. Winona uses a variety of cups, a fork, and a spoon when feeding herself. She eats well and enjoys a variety of foods including hamburgers, fruit, peas, and corn. A recent physical evaluation revealed that Winona is above the 95th percentile for her weight. MMHHBfe noted that she has introduced Winona to a more healthy diet and that Winona has since lost seven pounds. Winona is toilet trained and has recently stopped using pull-up diapers at night. Ms. >did not report any concerns with Winona's ability to dress/undress herself. Ms. stated that Winona currently sleeps in her own room in a twin bed. She takes naps on the weekend. When initially placed in Ms. iWHNB^home, Winona cried periodically during the night; this has significantly decreased. Winona exhibits some difficulty with washing, which may be related to her burn incident. She bites her finger and toe nails and plays with her saliva. Ms. MBB^Ktescribes Winona as a silly, sweet, funny, child who is sociable and enjoys hugs and affection when she initiates it. Winona loves outside play, Dora, Diego, and Sponge Bob characters. Winona's activity level is described as high and her attention span when playing alone is said to be short and fleeting. Winona runs often inside and outside. Ms. BBHHtodescribed Winona's "meltdowns" as screaming, thrashing, and crying when transitions occur. They are noted to be worse if Winona is sick or tired:J/\^king up and starting the day is said to be difficult. Although these behaviors still exist, Ms!*ttlVHHMnas seen ongoing progress and a decrease in behaviors since Winona arrived at her home. Winona is described to love other kids and will talk about her friends from school. She is said to have adjusted well to school and her teachers tell Ms.^HMUfcthat Winona seems to be enjoying herself at school. Impressions: Ms. ^rimpresses as a kind, caring, foster parent who is actively involved in all areas of Winona's wellness at this time. It is her hope that Winona can benefit from any service she is found eligible to receive. The CPSE process was discussed with Ms. Carbone and she was encouraged to call this worker with any future/questions.

Denise Anlgri Social Worker DA/vIc

JUST KIDS
Early Childhood Learning Center
Psychological Evaluation Name: Winona Piscitelli D.O.B.: 07/06/2005 Evaluatof: Diana DeStefano-DiLuca, M.A. Reason for Referral: Winona was referred for a psychological evaluation to determine eligibility for special education services. Concerns were noted regarding her articulation skills and possible sensory related problems. Relevant Background Information: Winona was removed frorrHTerrnother's care on September 16th due to neglect and now lives with her foster mother^BBHBfce. Winona sees her biological mother weekly for supervised visits. Her father is trying to get custody of Winona at this time, but is waiting on the results of a paternity test. Winona attends preschool at St. David's School in Riverhead. This is her first school experience. A conversation with her teacher reveals that Winona is a "good kid" who is trying very hard. She presents with some difficulty in her attentional skills and requires a fair amount of adult redirection in order to carryout assigned tasks. Winona gets along fairly well with her peers but has difficulty communicating her needs due to expressive language difficulties. A detailed social history report has been generated by the social worker and can be found on file. Behavioral Observations:
Middle Island Longwood Road P.O. Box 12 Middle Island, NY 11953 (631)924-0008 Phone (631)924-1243 Fax Lindcnhurst 887 Kellum Street Lindenhurst, NY 11757 (631) 884-3000 Phone (631) 884-1959 Fax Rlverhead 556 East Main Street Riverhead, NY 11901 (631) 369-1927 Phone (631) 369-1957 Fax William Floyd 99 Lexington Road Shirley, NY 11967 (631) 281-6800 Phone (631) 281-6096 Fax

Date: 11/3/2009 C.A.: 4:3

Stcvt Held Executive Director Stq>hen Gordon Director Cathy Cuniarano Director of Children's Services

Winona presented as a socially engaging and outgoing four year and three month old girl. She was immediately friendly. Winona unreservedly showed the evaluator her Dora bag and sippy cup. She took a general interest in the tasks presented to her, but needed a fair amount of prompting and direction to get started. Winona was somewhat self-directed but willingly accepted help and redirection. She appeared motivated to do well, but struggled to sustain her focus and concentration for the duration of the administration. Winona possessed a sweet nature. She smiled and worked cooperatively with the evaluator. Winona evidenced difficulty with articulation and word structure. She was unable to explain ideas in complete sentences and used gestures whenever possible to answer questions. Winona often repeated the questions back to the evaluator and often seemed not to understand what was being asked of her. Questions were repeated and directions were re-explained, as Winona needed additional teaching trials for most tasks. Winona's also evidenced weaknesses in her motor skills. She sometimes used a palmer grasp for increased support when holding her pencil. Winona had difficulty copying simple designs as well as with printing in the correct orientation (left to right). At the end of the evaluation, Winona waved to the evaluator and said, "Bye teacher."

Winona Piscitelli Assessment Procedures: Parent Interview

Psychological Evaluation

Page 2

Wechsler Preschool and Primary Scale of Intelligence - Third Edition (WPPSI-III) Mean = 100, SD = 15 Composite Standard Score 67 Verbal IQ 73 Performance IQ 69 Full Scale IQ 70 Global Language Composite Subtests Scaled Score Performance Block Design 5 Matrix Reasoning 9 Picture Concepts 3 Coding 7 Verbal 4 Information Vocabulary 4 4 Word Reasoning Global Language Receptive Vocabulary 5 Picture Naming 4 Average Range of Scaled Score

st

4th

ond 2nd

Range Extremely Low Borderline Extremely Low Borderline

%ile
5th 37th 1st 16th
ond ond

2nd

5th

= 8 to 12

Vineland II Adaptive Behavior Scales (Mean 100, SD=15) Domain Standard Score Communication 65 Daily Living Skills 77 Socialization 79 Motor Skills 81 Adaptive Behavior Composite 72 Achenbach Child-Behavior Checklist (CBCL) Syndrome Scales Emotionally Reactive Anxious/Depressed Somatic Complaints Withdrawn Sleep Problems Attention Problems Aggressive Behavior Internalizing Externalizing Total Problems

6th 8th 10th

1st

rd

Range Low Below Average Below Average Below Average Below Average

T-Score 55 50 50 51 59 53 58

Percentile
69th <50th <50m 54th

81st
62nd

79th
24th 76th 65th

Range WNL WNL WNL WNL WNL WNL WNL

WNL WNL WNL

43 57 54 *WNL= Within Normal Limits

Winona Piscitelli

Psychological Evaluation

PageS

Achenbach Teacher-Caregiver Form (CTRF) Syndrome Scales Emotionally Reactive Anxious/Depressed Somatic Complaints Withdrawn Attention Problems Aggressive Behavior Internalizing Externalizing Total Problems Assessment Results and Interpretation: On this administration of the WPPSI-III, Winona obtained a Full Scale IQ of 69. This score falls within the Extremely Low range and is representative of the 2nd percentile with respect to same-aged peers. The Full Scale IQ is derived from a Verbal IQ of 67 (1st percentile), which falls within the Extremely Low range, and a Performance IQ of 73 (4th percentile), which falls within the Borderline range. A General Language Composite was obtained to further assist in evaluating Winona's language skills. A score of 70, 2nd percentile was obtained. This score falls within the Borderline range. Subtest analysis of the Verbal domain reveals borderline range skills. Winona demonstrated delays in her ability to answer questions regarding general knowledge when presented with visual cues. She had difficulty labeling minor body parts and answering questions verbally. Winona identified 3 out of 12 pictures of common objects. She was unable to explain the function of objects. Winona also had difficulty identifying pictures of common concepts as well as with identifying concepts when the information was presented verbally. Subtest analysis of the Performance domain reveals scattered skills spanning from the extremely low to average range. Winona demonstrated extremely low range skills in her ability to understand increasingly abstract relationships between common objects. She demonstrated borderline range skills in her ability to perceive and manipulate visual patterns rapidly, such as in completing block designs. Winona demonstrated low average range skills in her ability to copy simple designs accurately and quickly. She demonstrated average range skills in her ability to identify and complete patterns. This is considered an area of personal strength. Winona's foster mother completed the Vineland II survey form. Based on her report of Winona's abilities in the Communication, Daily Living Skills, Socialization, and Motor Skills domains, her adaptive behavior scores fall within the low to below average range. Survey results from the Communication domain indicate Low range skills. Winona sometimes sits and attends to a story for 5 minutes; points to at least five minor body parts when asked; sometimes follows two-part instructions; sometimes tells about experiences in simple sentences; usually does not say her correct age when asked; identifies 2-5 common colors; and says less than 100 recognizable words. Winona does not yet use possessives or pronouns, nor does she use present tense verbs ending in "ing." T-Score 52 56 50 56 75 66 Percentile 58th
73rd <50th 73rd >97th 95th

Range WNL WNL WNL WNL Clinical Borderline

WNL Clinical Clinical

54 68 67

65th 97th 96th

Winona Piscitelli

Psychological Evaluation

Page 4

Survey results from the Daily Living Skills domain indicate Below Average range skills. Winona sometimes uses the toilet without help; puts on clothing that opens in the front; she does not yet fasten snaps or zip zippers; she sometimes brushes her teeth without help; sometimes clears unbreakable items from her place at the table; sometimes puts away personal possessions; is careful when around hot objects; sometimes uses the TV or radio without help; sometimes demonstrates appropriate behavior while riding in a car; and sometimes follows household rules. Survey results from the Socialization domain indicate Below Average range skills. Winona demonstrates friendship-seeking behavior with others the same age; sometimes responds appropriately when familiar adults make small talk; uses actions, but not yet words to express happiness or concern for others; has difficulty with social boundaries; sometimes plays cooperatively with more than one child; has difficulty with sharing and turn taking; says thank you when given something; sometimes responds appropriately to reasonable changes in routine; sometimes acts appropriately when introduced to strangers; and sometimes says she is sorry after hurting another's feelings. Survey results of the Motor Skills domain indicate Below Average range skills. Winona sometimes walks up and down stairs alternating feet; runs smoothly changing direction and speed; rides a bicycle with training wheels; sometimes catches a beach ball-sized ball from at least 6 feet away; holds a pencil or crayon in the proper position; can draw at least one recognizable form but does not yet make recognizable letters or numbers; has difficulty opening and closing scissors with one hand; sometimes colors simple shapes; and draws a circle freehand while looking at an example. Winona's foster mother completed the Achenbach Child Behavior Checklist (CBCL). Based on her response set, all scales fall within normal limits. However, during the interview with Winona's foster mother, concerns were noted regarding temper tantrum behavior and "meltdowns" (e.g., cries, yells, thrashes). It was also reported that Winona has difficulty transitioning and at times appears to be overstimulated by the environment. Winona is impulsive and hyperactive. She runs and jumps around the house and is rough with others. Winona resists taking naps. Winona's teacher completed the Achenbach Caregiver-Teacher Report Form (CTRF). Based on her report of Winona's classroom behavior, the following scales yielded elevated scores: Borderline range- Aggressive Behavior Clinically Significant- Attention Problems These findings reveal that at school Winona has great difficulty concentrating; cannot seem to sit still; sometimes has difficulty following directions and carrying out assigned tasks; is often inattentive; sometimes hits or gets into fights with others; is often defiant; and does not seem to feel guilty after misbehaving. Summary and Impressions: Winona is a four year and three month old girl who attends preschool al4MMHBfc School in CMMfe!. She was referred for testing due to concerns regarding her articulation skills and possible sensory related problems. Based on the current evaluation, Winona's intellectual skills are measured to fall in the Extremely Low range. Her overall IQ is assessed to be 69, representative of the 2nd percentile. This score is comprised of a Verbal IQ of 67 (1st

Winona Piscitelli

Psychological Evaluation

Page 5

percentile), which falls within the Extremely Low range, and a Performance IQ of 73 (4th percentile), which falls within the Borderline range. Winona demonstrated widely scattered skills between the extremely low and average range of intelligence. A personal strength was noted in her ability to identify patterns. According to the responses from the Vineland II, completed by Winona's foster mother, she demonstrates low range communication skills, and below average self-help, socialization, and motor skills. Based on the responses to items on the Achenbach Child Behavior Checklist (CBCL) all scores fall within normal limits, however, these results are not commensurate with the concerns noted during the interview. Responses to items on the Caregiver-Teacher report form resulted in a Borderline score on the Aggressive Behavior scale and a Clinically Significant score on the Attention Problems scale. According to this evaluation, Winona is exhibiting delays in her nonverbal and verbal reasoning skills as well as in her general concept development. Winona continues to have difficulty identifying colors and does not yet recognize letters of the alphabet. During this evaluation, she had difficulty answering questions verbally and responded in very simple and short phrases. Winona presents with attentional difficulties and tendencies toward aggressive behavior. In the classroom, Winona requires a fair amount of adult redirection in order to follow instructions and carryout assigned tasks. These behaviors were also observed during this oneto-one evaluation. At this time, it is recommended that Winona receive the additional support of special education services in a firm and structured educational setting in order to develop her cognitive, academic, and social-emotional skills. Final determinations for programs and services are to be established by the CPSE.

Diana DeStefano^DiLuca, M.A. School Psychologist

JUST KIDS
Early Childhood Learning Center
Preschool Speech Language Evaluation 2-Name: Winona Piscitelli $DOB: 7/6/05 C.A.: 4 years, 4 months School District: DOE: 11/3/09 Evaluator: Lisa Valenti, MACCC/SLP
Steve Hdd Executive Director Stephen Cordon Director Cathy Cunhrano Director of Children's Services

BACKGROUND AND REFERRAL INFORMATION: Winona was referred to Just Kids for a speech and language evaluation in order to assess her need for CPSE services. Ms. HMB> Winona's foster mother, expressed concern regarding Winona's speech and language development; particularly her limited intelligibility and language comprehension. Ms.<ttMHBhas limited information regarding Winona's medical and developmental history. Since Winona's placement, she has had a few colds; otherwise she appears to be healthy. **Please refer to Social History section of this report for more comprehensive information regarding developmental milestones and medical background. BEHAVIORAL OBSERVATIONS: Winona was immediately friendly and outgoing as testing commenced. She was reluctant to participate in formal testing; instead she gestured toward the toy cabinet and asked to "play". The evaluator attempted to redirect her to her chair, however she called for her foster mother and stood by the table next to Ms. Carbone instead. She completed a few language test items and became distracted (e.g. laid across the table, independently turned pages of the test manual, labeled the pictures). The evaluator presented articulation tests slates and Winona's attention improved. She named the items and smiled proudly in r esponse to verbal praise. She easily transitioned back to language testing and was able to complete her assessment successfully. During informal play, Winona used toys appropriately and allowed the evaluator to participate in her activities. She was somewhat congested during testing and often had to take "breaks" to wipe her nose and drink her water. Despite her obvious discomfort, Winona was engaging and cooperative. No temper tantrum behavior was noted. [EVALUATION BATTERY: I. Preschool Language Scale-4 (PLS-4). A norm referenced test that assesses auditory :omprehension and expressive communication in children ages' birth to 6 years. Standard Score 65* 64* 61* Percentile Rank 1st 1st 1st Standard Deviation >-2.0 sd >-2.0 sd >-2.0 sd

Middle Island Longwood Road P.O.Box 12 Middle Island. NY 11953 (631)924-0008 Phone (631)924-1243 Fax Lindcnhurst 887 Kellum Street Lindenhurst, NY U757 (631) 884-3000 Phone (631) 884-1959 Fax
Riverhead 556 East Main Street Riverhead, NY 11901 (631)369-1927 Phone (631)369-1957 Fax

Auditory Comprehension: Expressive Communication: Total Language:

William Floyd 99 Lexington Road Shirley, NY 11967 (631 (281-6800 Phone (631) 281-6096 Fax

Winona Piscitelli

Speech/Language Evaluation

Page 2

2. The Goldman-Fristoe Test of Articulation - a norm referenced test that provides a systematic means of assessing articulation problems in individuals between the ages of 2-0 and 21 years. Standard Score Percentile 60* 3rd

3. Khan Lewis Phonological Analysis- for use with the Goldman Fristoe Test of Articulationthe KLPA-2 is a norm-referenced test that provides a systematic means of assessing phonological processing in individuals between the ages of 2-0 and 21 years. Standard Score Percentile 49* <lst

*Standard Score is based on a mean of 100 +/-15 4. 5. 6. 7. Hearing Status Language Sample Oral Peripheral Examination Clinical Observation

INTERPRETATION OF TEST SCORES: PLS-4: Receptive Language Skills: The auditory comprehension section of the PLS-4 is used to evaluate how much language a child understands. The tasks designed for preschool-age children assess comprehension of basic vocabulary, concepts and grammatical markers. Formal language testing revealed a significant delay in Winona's receptive language skills with a standard score of 65 and a corresponding percentile rank of 1. She pointed to pictures that depicted object function (e.g. what you ride), part/whole relationships (e.g. door of the car), negatives in sentences (e.g. not crying) and simple descriptive concepts (e.g. big, little). She followed two-step related directions presented with verbal cues only (e.g. get the cup and give it to me). She identified colors accurately. Winona did not demonstrate an understanding of quantity concepts (e.g. one, all), gender specific pronouns (e.g. her, his), picture analogies (e.g. you sleep in a bed, you sit on a chair) or categories of objects in pictures (all the things we eat). She did not make inferences when she was presented with an outcome and several pictures of situations that may have resulted in that outcome (e.g. Charlie's shoes got all wet - what do you think it was like outside? raining). Expressive Language Skills: The expressive language section of the PLS-4 is used to determine how well a child communicates with others. Preschool-age children are asked to name common objects, use concepts that describe objects and express quantity and use specific prepositions, grammatical markers and sentence structures. Formal language testing revealed a significant delay in Winona's expressive language skills with a standard score of 64 and a corresponding percentile rank of 1. She sought attention from others. She answered "what" and "where" questions appropriately (e.g. what is she holding? "pillow"). She used an Is! to mark for regular plurals (e.g. blocks). She used a variety of nouns, verbs, modifiers and pronouns in spontaneous utterances. She produced basic four to five word sentences. She named a variety of age

Winona Piscitelli

Speech/Language Evaluation

Page 3

appropriate pictured objects (e.g. scissors, monkey). She used quantity words when she was asked to count items in a picture. Winona did not use the present progressive form of verbs (e.g. eating) or an /'si to mark for possession (e.g. cat's) She did not use words that describe physical state (e.g. hungry, thirsty). She did not answer questions logically (e.g. what would you do if your hands were dirty) nor did she answer questions about hypothetical events (e.g. what should you do if you feel sick). She did not complete analogies (e.g. noodles are for eating, milk is for). Language Sample: A language sample was collected yet could not be accurately analyzed as Winona's intelligibility was significantly compromised by speech sound production errors; particularly in connected utterances. The evaluator relied on contextual cues and her foster mother's translations in order to infer Winona's meaning. Some of her utterances are transcribed below and translated when possible: Ah pida (where pizza) Ah da baby (where the baby) Ah dah nah working (...that not working) Ah bah dow (...push down) Iz a baby barah (it's a baby pillow) Ka peez (cup please) Look a kahpi A din a deeza Waeeoff Ei geh off A barah (a pillow) Wa go oudai (wanna go outside)

Social Language: According to the language sample checklist of the PLS-4, Winona's pragmatic skills during today's evaluation splinter into the 3-4 year old age range. She told about an object. She used language to control another person's behavior. She used language to interact with others. Winona did not talk about events or recent experiences. She did not maintain a conversation. GFTA-2 and KLPA-2: Articulation: The Sounds-in-Words section of the GFTA-2 provides several summary normative scores. The GFTA-2 standard score provides a means to compare one individual to another based on age and gender. A percentile rank indicates the percentage of individuals in the population that performed at or below a particular score. The percentile is derived from the standard score and it permits us to determine an individual's position relative to the reference group. The Soundsin-Words section was administered on 11/3/09. Winona's standard score of 60 represents performance on the GFTA-2 Sounds-in-Words section at the 3rd percentile of females her age and is considered to be in the significantly below average range.

Winona Piscitelli

Speech/Language Evaluation

Page 4

Speech sounds are mastered developmental^ in a typical order as people grow and learn. A large and well-controlled sample allows valid judgments about individual performance in developmental acquisition of sounds. A criterion of 85% was used to determine significance and need for planning. In other words, if 85% or more of Winona's age or age and gender peers have mastered a sound in a specific position and Winona has not, then it may be a sound that requires intervention. The following table lists the sounds produced incorrectly or omitted by Winona and the percentage of her age and gender peers that successfully articulate the sound. GFTA-2 Developmental Norms % Mastery of Sound Sound Position Initial Medial Medial Medial Medial Medial Medial

/ml IV Idl
/ng/

l\l Ibl Kl Id/ N

/ten/ /dch/

ni

Final
Final Final Final Final Final

Gender Total 96% 92% 92% 89% 92% 92% 87% 94% 87% 90% 83% 87% 87%

Population Total

94% 95% 90% 87% 91% 96% 76% 89% 89% 84% 87% 79% 84%

Phonology: The Khan-Lewis Phonological Analysis-Second Edition (KLPA-2) is a norm-referenced analysis of an individual's speech development and phonological process usage. The analysis is used to identify frequency of usage of ten distinct phonological processes grouped into three categories (Reduction Processes, Place & Manner Processes, and Voicing Processes), and any other processes used by the individual. The KLPA-2 requires the administration of the 53 target words of the Goldman-Fristoe Test of Articulation-Second Edition (GFTA-2). The target words are analyzed for any sound changes and the sound changes are classified by phonological process. The total number of sound changes is converted into a series of scores based on ageand gender-based norms. The Khan-Lewis Phonological Analysis-Second Edition (KLPA-2) was administered on 11/3/09. Qualitatively, the examiner's impression of Winona's overall intelligibility is poor. Quantitatively, when compared to her age and gender peers, her raw score converts to a standard score of 49 and reflects overall intelligibility at or better than <1% of females her age which is in the significantly below average range. The following developmental phonological processes were exhibited: Process Deletion of Final Consonants Syllable Reduction Stopping % of Occurrence 27(WNL until age 3.0) 31 (WNL until 3.0) 45 (WNL until age 3-5)

Winona Piscitelli Process Cluster Reduction Liquid Simplification Velar Fronting Palatal Fronting Deaffrication Initial Voicing Final Voicing

Speech/Language Evaluation % of Occurrence 73 (WNL after age 3) 23 (WNL after age 3) 21 (WNL after age 3) 22 (WNL until age 3) 50 (WNL after age 3) 42 (WNL until age 3) 13 (WNL until age 3)

Page 5

Winona was intelligible to the evaluator approximately 75% of the time in connected speech when contextual cues were available and less than 50% of the time in unfamiliar situations. Winona's consonant speech sound production ability and her phonological process usage are both in the significantly below average range. *Please note that transcription is in the standard alphabet in order to better illustrate how the words sound for persons unfamiliar with the phonetic alphabet. INTERPRETATION OF INFORMAL ASSESSMENTS: Oral Motor and Feeding Skills: Oral motor skills were assessed via parental reports. Ms. ttMfcMfcreported that Winona tolerates foods that vary in taste, texture and temperature. She drinks from a sippy cup, open cup and straw. She does not use a pacifier or suck her thumb for comfort. Upon informal observation, all oral peripheral structures were symmetrical and had adequate range of motion for speech and vegetative purposes. Overall, oral motor skills were age appropriate. Audition: Winona responded to speech and environmental sounds presented bilaterally. Please refer to full audiological evaluation included as part of her CPSE packet for comprehensive information regarding hearing status. Voice: Winona presented with a slightly hyponasal quality to her voice that appeared to be the result of nasal congestion. Otherwise, her vocal parameters were appropriate for her age and gender. Fluency: Winona produced multi-word phrases fluently during this evaluation. SUMMARY AND RECOMMENDATIONS: Winona presents as a delightful, social and engaging child. Formal language testing via the PLS-4 reveals a significant delay in Winona's receptive language skills with a standard score of 65 and a corresponding percentile rank of 1. Expressive language skills are comparable with a standard score of 64 and a corresponding percentile rank of 1. Winona's total language standard score is 61 with a corresponding percentile rank of 1. Winona's standard score of 60 and percentile rank of 3 suggests a significant delay in her articulation skills as per the GFTA-2.

Winona Piscitelli

Speech/Language Evaluation

Page 6

Winona's standard score of 49 and corresponding percentile rank of <1 indicates a significant delay in phonological process usage as per the KLPA-2. Oral motor skills are adequate for speech and vegetative purposes. Hearing was formally assessed by the audiologist (please refer to audiological evaluation included in this CPSE report for comprehension regarding Winona's hearing status). Voice is adequate for Winona's age and gender; a slight hyponasal quality was noted that appeared to result from nasal congestion. Multi-word phrases are produced fluently. Syntax could not be accurately assessed secondary to limited intelligibility. Pragmatic skills are grossly age appropriate. Winona's scores suggest a significant delay in her speech and language skills at this time. Eligibility criteria are met for services through her school district's CPSE program. It was a pleasure working with Winona and her foster mother during today's evaluation. Ms. Carbone is encouraged to call any provider working on her evaluation team at any time with questions or concerns. This recommendation is to be considered within the total decision making context of the CPSE meeting where actual determination of services is made.

Lisa Valenti, MACCC/SLP Speech Language Pathologist License #: 007745 **l certify that I personally evaluated the above named child, employing age appropriate testing instruments and procedures as well as informed clinical opinion. I have discussed the results of this evaluation with the family. The family was also given Just Kids' contact number should they have any questions.

j JUST KIDS

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Early Childhood Learning Center

Audiological Evaluation

Steve Held Executive Director Stephen Gordon Director Cathy Ctanfirano Director of Children's Services

< Name: Winona Piscitelli U D.O.B.: 7/6/05

Date: 11/3/09 Examiner: Diane Davis, AuD, CCC-A

Winona Piscitelli, age 4 years 4 months, was seen for an audiological evaluation on 11/3/09. She was accompanied by her foster mother who acted as informant. She reported that she does not feel Winona is exhibiting hearing difficulties. She stated that Winona was recently seen by her physician and she had some middle ear fluid. There are reported concerns about Winona's articulation. Results Results of play audiometry were considered to be of good reliability in indicating normal hearing sensitivity from 250-4000 Hz in both ears. Speech reception thresholds were in good agreement with pure tone findings at 15 dBHL bilaterally. Speech discrimination ability was excellent at 92% in each ear. Tympanometry testing revealed normal middle ear systems compliance and normal tympanic peak pressure (Type A) in each ear. Summary Winona is exhibiting normal hearing sensitivity from 250-4000 Hz in both ears. Speech reception thresholds were normal and speech discrimination ability was excellent in each ear. Tympanometry testing was suggestive of normal middle ear function bilaterally. There are no further audiological recommendations at this time.

Middle Island Longwood Road P.O. Box 12 Middle Island. NY 11953 (631) 924-0008 Phone (631)924-1243 Fax Lindcnhurst 887 Kellum Street Lindenhurst, NY 11757 (631) 884-3000 Phone (631) 884-1959 Fax Riverhead 556 East Main Street Riverhead, NY 11901 (631)369-1927 Phone (631)369-1957 Fax William Floyd 99 Lexington Road Shirley, NY 11967 (631) 281-6800 Phone (631) 281-6096 Fax

Diane Davis, AuD ,CCC-A Audiologist DDgl

JUST KIDS s~ Diagnostic and Treatment Center Inc.

Longwood Road Middle Island New York (631) 924-0008 Mailing Address: P.O. Box 12 Middle Island New York 11953

AUDIOLOGICAL TEST INFORMATION

NAME
DATE

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WEBER

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COMMENTS

J C

JUST KIDS
Early Childhood Learning Center
Occupational Therapy Evaluation Date: November 6, 2009 Evaluator: Lisa Lanzarotta, OTR/L Introduction:

UJ

Steve Held Executive Director Stephen Gordon Director Cathy Cunfarano Director of Children's Services

< Name: Winona Piscitelli DOB: 07/06/05 CA: 4 years 4 months

Winona is a 4 year 4 month old girl who was referred for an occupational therapy -evaluation due to concerns of fine motor coordination delays and sensory processing difficulties as it impacts on function. This evaluation was approved by the taHgMMr* school district and will assist in determining eligibility criteria under the provisions of section 4410 of the education law. J"his_evaluation was conducted at Winona's pre-schooljfc jflMMHer foster mother, BJMMHIfe was present for the evaluation. The purposes and procedures of this evaluation were explained to Ms.*AHHIfcnd the consent was signed. Behavioral Observation: Winona was tested in an empty classroom with her foster mother present. She happily greeted the evaluator and she was easily directed to the table for standardized testing. When she entered the room Winona was already engaging in coloring with a marker and paper. With some verbal prompting she was directed to table top testing. During most testing items Winona preferred to stand rather than sit. Occasionally she required rewards with stickers to engage in activities such as block design imitation. Winona appeared distracted at times, however she presented with a runny nose due to a cold. Ms. flrtMBreported Winona was slightly out of sorts due to having a cold. With verbal prompting, praise and rewards Winona did engage in all presented tasks. When she did engage in any particular task she focused well carrying the task through. Testing items that required only a verbal directive, such as folding paper, Winona had difficulty performing the task. When a visual demonstration was provided Winona was then able to complete the requested task. Evaluation Methods: Winona was evaluated using the Peabodv Developmental Motor Scales-2nd (PDMS2). Test of Visual Motor Skills-revised (TVMS-R), Sensory Profile- caregiver questionnaire, clinical observation, therapeutic handling, and parent report. Orthopedic/Neuromuscular Status: Winona's muscle tone appeared in low-normal ranges throughout trunk and upper extremities. Her muscle strength appeared within good ranges grossly throughout based on observation of play with novel toys and movement within her environment. Winona's vision appeared adequate for the purposes of this evaluation. She appeared to hear localized sounds but she responded well to her name. Protective reactions were present. Her righting and equilibrium reactions were present and incorporated into dynamic movement.

Middle Island Longwood Road P.O. Box 12 Middle Island. NY 11953 (631)924-0008 Phone (631)924-1243 Fax Lindenhurst 887 Kellum Street Lindenhurst, NY 11757 (631) 884-3000 Phone (631) 884-1959 Fax Rlverhead
556 East Main Street Riverhead, NY 11901 (631)369-1927 Phone (631)369-1957 Fax

William Floyd 99 Lexington Road Shirley, NY 11967 (631) 281-6800 Phone (631) 281-6096 Fax

Winona Piscitelli

Occupational Therapy Evaluation

Page 2

Winona ambulated independently. She jumped in a forward motion with two feet together. She was able to hop on one foot unsupported and hop in a forward direction. Winona was unable to stand on one foot unsupported. She was able to weight shift in order to kick a moving ball. Winona was able to throw and catch a ball. Ms. Carbone reports Winona is able to pedal a tricycle. Winona's gross motor skills appear within age limits based on informal assessment through clinical observation. Fine/Visual Motor Skills: The PDMS-2 was administered to assess Winona's current level of fine/visual motor skills. Areas assessed were grasping; the way one holds and manipulates objects and visual motor integration; the way one use their eyes and hands together for task performance. The PDMS-2 revealed the following scores: Skill Grasping Visual Motor Integration Fine Motor Quotient = 88 Standard Score 7 Percentile Rank 16th Standard Deviation -1.0
-0.5 -0.8

Range

Description Below Average Average Below Average

6-7
8-12

37m
21st

80-89

Winona appears to have a right hand preference as she held and manipulated most objects with using her right hand. She is utilizing a dynamic tripod hold on a marker and pencil. Winona uses a neat pincer grasp when picking up small objects such as beads and cereal. She uses a 3-jaw top hold on cube blocks. Winona uses an appropriate thumb up hold on a scissors. She is not yet able to manipulate buttons to open and close with just a verbal directive. With a visual demonstration Winona did open a button. In terms of Winona's visual motor skills, she copied a closed circle (33-34 months) on her second trial. She demonstrated decreased accuracy to copy a cross (41-42 months) as the intersecting lines were more than twenty degrees from the perpendicular. She required two trials to copy a cross. Winona drew a circle in her attempts to copy a square (49- 50 months). She was unable to imitate a square. She could not carry out the verbal directives to connect two dots with a line (53-54 months) and she responded with drawing circles around the dots. Winona was able to build a nine cube block tower (29-30 months). She exhibited good visual perceptual skills Winona with imitating block designs such as a bridge (31-32 months), a wall design (35-36 months), replicating steps (51-52 months) and a pyramid (53-54 months). Winona approached scissors with a pronated hold to cut across paper (37-38 months). With the visual cues of lines she was able to use a thumb up hold on scissors. She was able to cut along a line (41-42 months) within a 1/2" of the line. However her cuts were choppy. Cutting out shapes was a challenge for Winona. She did attempt cutting a circle (49-50 months) and a square (53-54 months), but was unable to complete the tasks with coordination both hands together well. Winona was able to string beads (27-28 months) with good coordination and control. She laced a strip by following a running stitch (39-40 months). Initially she laced incorrectly, but

Winona Piscitelli

Occupational Therapy Evaluation

Page 3

recognized her mistake and then self-corrected. She was able to drop small pellets into a bottle one at a time within 30 seconds (41-42 months). The TVMS-R was also administered to further assess Winona's design copy abilities as she exhibited difficulties with copying a cross and a square on the PDMS-2. Design copy is a prerequisite to letter/number formation, writing and reading. This test isolates design copy and assesses eight classifications of visual-motor perceptual skills: closure, angulations, intersection, sizing (gradation), rotation/reversal, line length, over/under and modification. Therefore can further illustrate and identify areas of weakness. When tested with the TVMS-R. Winona demonstrated difficulties with sizing (gradation), line length, rotation/reversal and over/under modification. Winona did not complete all designs. Designs such as a double circle, an oval, a rotated "T", an "L", rectangle, three small squares and a triangle were challenging for Winona. According to the TVMS-R. Winona received the following scores: Standard Score: 68, Percentile Rank: 2nd, Standard Deviation: >-2.0. Sensory Status: Mrs.^BHptwas provided with the Sensory Profile- careqiver Questionnaire to provide information regarding Winona's sensory processing abilities. Sensory processing is the way one takes in information from the environment and his/her own body, registers the information, interprets the information, organizes the information and produces an adaptive response. The Sensory Profile reveals three area of weakness with Winona's sensory processing abilities. She received a Probable Difference score (=/> -1.5 SD below the mean) in Touch Processing, Emotional/Social Responses, and Behavioral Outcomes of Sensory Processing. Winona is described to frequently respond negatively to hair washing. Ms.4MMHle reports that Winona does not like the water running down her face associated with hair washing. Occasionally, Winona will become irritated with wearing shoes and socks and prefers to be barefoot. Reportedly Winona will occasionally awake during the night crying and possibly having nightmares. She will tend to cry easily and she frequently has difficulty tolerating changes in plans routines. Clinical observation noted distractibility; however Winona was redirected with minimal effort. The Sensory Profile indicates minor difficulties with processing sensory information with over responsiveness noted. Self-Care Skills: The following information was obtained via interview with Ms. 4HHtet Reportedly Winona drinks from a straw and an open cup. She uses a spoon and a fork independently with some spilling. She can pour a drink from a pitcher. Winona can doff shoes, socks, coat and pants. She has emerging abilities to don socks and shoes. She can wipe her nose with a tissue and wash her hands. Evaluation Summary: Standardized testing with the PDMS-2 reveals Winona's fine/visual motor skills are within normal limits. Her fine motor quotient was an 88 with a standard deviation of -0.8 below the mean and placing her overall skills in the 21st percentile. The TVMS-R reveals significant delays in the area of design copy. She received a standard score of 68 revealing a standard

Winona Piscitelli

Occupational Therapy Evaluation

Page 4

deviation of greater than -2.0 below the mean. The Sensory Profile reveals delays with sensory processing. These sensory processing delays do not appear to impact skill acquisition. Overall results of testing indicate that Winona presents with generally age appropriate fine motor skills. She evidenced some slight difficulty with cutting out shapes and she required visual demonstration to perform several tasks. She uses a mature grasp on a writing implement and demonstrates good graded control. Significant difficulty was noted with design copy, however, this may be due to limited exposure to these types of tasks. At present, Winona does not appear eligible for OT services. A re-evaluation in 6 months is recommended should Winona continue to display difficulty with copying graphomotor designs. Final determination of eligibility criteria and frequency of services is made by the CPSE.

6TTL/L
Lisa Lanzarotta, OTR/L Registered Occupational Therapist License #-009510-1

OCT.15.2009 14:06 2812118 10/15/2009 13:02 FAX 631 924 42

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STEVE LEVY SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF SOCIAL SERVICES GREGORY J. BLASS COMMISSIONER

Date: 10/1/09
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Dr. Penzer 990 Westbury Rd., Ste. 100 Westbury,NY 11590

RE: Winona Piscitelli, dob: 7/6/05 Dear Sirs/Madam: Please find enclosed medical/school release in reference to the above-named client(s). We would appreciate your forwarding all pertinent information regarding this family to this agency, in care of the undersigned, at your earliest convenience. If you have any questions, please feel free to call me at 854-9139. Thank you for your attention to this matter. Very truly yours, Lisa Scafide Caseworker, Team 63/102 Robert Leto Supervisor, Team 63/101 Child Protective Services If school: Psychological Psychiatric Attendance Grade-Academic Performance Peer and social relationships Medical and/or hygienic information Progress reports If medical: Specific information All medical records Any concern Treatment Attendance

BOX 18100

HAUPPAUGE, N.Y. 11788-8900

(631) 854-9935

Authorization for Release of Protected Health Information (PHI)

Patient Information Name: Address: Date of Birth: Q- L? -Q

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I hereby authorize the use and/or disclosure of my protected health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. To: (Name and address of person, facility, and/or program disclosing information) From: (Name, address and title of person and/or organization to which disclosure is to be made)

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Treatment plan Dates of treatment I I Discharge summary record/Other:

Purpose or need for protected health information: Child Protective Services Investigation/ provision of services. I understand that the above information is protected by Federal Regulations 42 CFR, Part 2, "Confidentiality of Alcohol and Drug Abuse Patient Records" and cannot be disclosed without my consent unless otherwise provided for in the regulations. I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do it won't have any effect on any action they took before they received the revocation. I understand that this permission will expire when acted upon, or ninety (90) days from this date, whichever comes first. Print Name: Signature: Date:

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N.Y. State Eligibility Code:
Paul H. Penzer, M.D., F.A.A.P. Michael J. Everoskl, M.D., F.A.A.P. Jeanette Alvarenga, D.O., F.A.A.P. Birth date: 990 Westbury Road, Suite 100 Westbury, New York 11590 Telephone: (516) 333-4100 e Fax: (516) 333-4255 Record #: "I have been provided a copy of the appropriate Centers for Disease Control and Prevention Vaccine Information Material(s) and have read, or have had explained to me, information about the diseases and the vaccines listed below. I have had a change to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccines cited, and ask that the vaccine(s) listed below be given to me or to the person named above (for whom I am authorized to make this request)."

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LAST NAME: PISCITELLI

FIRST: WINONA WESTBURY

ADDRESS: 318 ELLISON AVENUE H: 516 333-2672 W: GUARANTOR: SPOUSE: WINONA

NY 11590

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Patient Name

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No Change

Allergies

Medications Changes in Family Medical or Social History No Change

None

Parental Concerns Raised

None

Physical Examiilation N A General Head Eyes Ears Nose Mouth/Throat Neck Chest/Back Cardiac Pulmonary Abdomen Pelvis Musculo skeletal Neurologic Skin Assessment/Plan

Development ASQ Communication Gross Motor Fine Motor Problem Solving Personal/Social (circled values indicate out of range) Results Discussed: Y N Patient referred: Y N ASQ:SE \ \ (circled value indicates out of range) Results Discussed: Y N Patient referred: Y N Guidance/Counseling Milestone Expectations Safety Daycare/School Immunizations Nutrition Current Food Intake Counseling Exercise Diet Planning Risk Factors Target weight goals (by date) Procedures: Ear Curettage Ear Piercing: Gold Diamond Forms Filled out

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Follow Up:

PRACTICE LIMITED TO PEDIATRICS & ADOLESCENT MEDICINE

Date

Name

\M * r\ Date of Birth

Birth and Delivery: Normal Neonatal Problems at Birth: No Birth Wt:. Feeding: Breast Past Hospitalizations: None Yes: >v^r

CIS Yes:

Breech

Discharge Wt: Formula

. Amount/. Or Time

Frequency

Serious Illnesses: None Yes: Medications: None.

Yes.

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Age

Health and/or Allergies

Mother Father Sibling Sibling Sibling Family History

Ht Disease, M.I. or Stroke before age of 50: Yes T.B. or T.B. contact: Yes Diabetes: Yes No No

Development
No
Sits

Stands . Cruises Walks _ Speech

Other Significant Problems (patient or family)

Freed, Sc^rz, Klecnberg, Nussbaum, F&*ta, L.L.P. & Associates

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IMMUNIZATIONS
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Date

Date

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Stature-for-age and Weight-for-age percentiles

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Record #.

Mother's Stature Father's Stature Date

12 13
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O 2007 Abbott Laboratories Inc

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TUST KIDS
AUTHORIZATION FOR RELEASE OF INFORMATION _J|Vj_

Early Childhood Learning Center

B <
Sieve H f l d Uxcculi'C Dircrfor Sicplicn Cftrdon

Cl ilds Name: DCte of Birth:

Records Requested:

0rtT>mU/WC gJUfofl)''*

>irccror of Children^ Service:

I give permission for Just Kids Diagnostic and Treatment Ce nter to release and obtain such information as may be necessary to and from the following individual and/or agency:

Nc me:
Ac dress:

Tc wn :
Tclephone: Tl is information may include record of medical, educational, pi ychological, social history," speech and hearing, and pi ysical and occupational evalua^TTori&v and/or therapy. S: gnature:

Parent/Lej^al Guardi) |JX

Ac dress:
Middle Ulantl

ster Parent

P.O. Bux 12,

Longwood Rond Vlicldle Island, MY 11953
;631) 924-0008 Phone

9
10V

dtDi

;&31) 924-1243 F;ix LiriJenliurst UB7 Kellvtm Street Lindenhurst, NY

11757

D; te:

(631) 884-3000 Phone (631) 884-1959 Fnx Rivcrlicacl 540 East Main Street Riverhead, NY 11901 ;f>3 1)369- 1927 Phone ;e.ll) 369-1957 F;u Hoyd
Shirley. NY 11 96 7

- -

Just Kids Diagnostic and Treatment Center Use Only;

631)7.81..6800 Phone 631 } 281 -6096 Fx

Cl ild is pending evaluation Cl ild is currently pending placement CJ .ild is currently in program Pi ease obtain information P.' ease release information n lofinfo.Iw