New Jersey Early Intervention System



NEW JERSEY EARLY INTERVENTION SYSTEM

DEVELOPMENTAL ASSESSMENT SUMMARY

|Child’s First Name |Child’s Last Name |MI |Child’s SPOE Id # |

|      |      |      |      |

|Child’s Date of Birth |Assessment Date |Chronological Age       |County of Residence |

|      |      | |      |

|Developmental Assessment Location |Start Time |End Time |

|      |      |      |

|Developmental Area(s) Assessed: |

|Adaptive Social/Emotional Communication Gross Motor Fine Motor Cognitive |

|Developmental Assessment Tools in addition to Parent Report and Clinical Observation |

| Discipline Specific Assessment Instruments |Specify:       |

| |Specify:       |

| Other Instruments |Specify:       |

| |Specify:       |

|REASON FOR ASSESSMENT |

|      |

|ASSESSMENT SUMMARY |

|Mastered Skills: |

|      |

| |

|Emerging Skills: |

|      |

| |

|Developmental Learning Skills Targeted for Next 6 Months: |

|      |

| |

|Describe qualitative concerns and atypical behavior or developmental patterns identified that are affecting the child’s functioning in daily routines. |

|      |

| |

| |

| |

| |

|Describe the clinical observations indicating subsequent development that will be affected without early intervention services. |

|      |

| |

| |

| |

| |

|ASSESSMENT TEAM PARTICIPANTS |

|Name (Print) |Title/Discipline |Agency |Minutes |Signature |

|      |Parent/Guardian |N/A | | |

|      | | | | |

|      | | | | |

|      | | | | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download