

Patient History / In-Take Form
Download and print this PDF to fill out new patient information before coming in for your first appointment / consultation.
Patient Feeding In-Take Form
Coming Soon.
“EI”
Early Intervention is a program by New York State and New York City Department of Health. This is an interagency program for the age 0-to-3 years population with developmental delays in their efforts to realize their full potential. Visits are approved under the IFSP – Individualized Family Service Plan guidelines. The child exits the program at age 3 in either January or August, based on their date-of-birth. The genesis of the program dates to the passage of the Individuals with Disabilities Education Act by Congress in 1986 (Public Law 99-457).
The New York City Department of Health and Mental Hygiene is lead NYC agency; the NYS Department of Health coordinates the statewide network of services.
Information: http://www.ldanatl.org/aboutld/professionals/guidelines.asp
EI – City of New York Information at:
http://www.nyc.gov/html/doh/html/earlyint/earlyint.shtml
DOE & RSA’s
For the Department of Education, speech and language services are considered a Related Service. Heather Boerner maintains an RSA-Related Service Agreement with the Department. Services provided are mandated through an IEP- Individualized Education Plan. Related services are defined as developmental and corrective support services, which are required to assist a student with a disability to benefit more fully from their school based education. Based on a student’s Individualized Educational Program (IEP), related support services can be provided. This includes Speech/Language Therapy.
NYC information at:
http://schools.nyc.gov/Offices/District75/Departments/RelatedServices/default.htm
http://schools.nyc.gov/Academics/SpecialEducation/ParentResources/Related+Services+Information.htm
http://schools.nyc.gov/Offices/District75/Departments/RelatedServices/ORCS/default
CPSE
The Committee on Preschool Special Education is for children ages 3-to-5 years, and requires a referral from parents. Evaluations are conducted by the Department of Education and services are delivered and provided by approved providers (Heather Boerner is an approved provider). The program can begin once the child is three (3) year old and terminates at the initiation of kindergarten. Many school districts are sources of more information and each district is assigned a service coordinator to assign service mandates (frequency and duration of services provided each week.)
More information here (sample):
http://www.blindbrook.org/district_info/district_information/pupil_services/cpse.shtml
CSE
The Committee on School-Age Special Education. This program begins when the child enters into kindergarten and related services can be provided under this system until the child is 18 years of age. Again, department of education evaluators determine if the services are warranted based on the child’s degree of disability in the area of speech and language development.