Please click on a link below to download a form.

NYCDOH-EIP Forms -Effective Sep-Oct-2024
Consent for Telehealth Change Form- ISC -Add units-Duration-Extend SA-Change Change of Services-SV Provider Consent for Evaluation or Screening From Consent Obtain Release Info NYCDOH Initial Service Coordination Consen Progress Report-NYCDOH Reason for Delay in Evaluation Completion and MDE Submission Form Request for Supplemental Evaluation-Parent-NYCDOH Consent for Additional Evaluation -11 2024	Invoice Summary of Services Itinerant Monthly Billing Form Itinerant Monthly Billing Forms - Resubmission Billing Form for EIP Evaluations Billing Invoice Translation Calendar-Billing/Payment Schedule Calendar-Billing-2025	Parental Consent to Use Interventionist w Formal Plan of Supervision Parental Consent to Use e-Mail Consent for the use of Electronic Software Docusignl Parental Confirmation Form Letter Incident Report Record Of Injury Explanation for delay / Interruption of Services Community DayCares Health & Safety Survey NYSDOH Home Health Safety Survey NYSDOH EMERGENCY ALERTS TO Parents 5 Day Interruption Notification-Therapist-EI 30 Day Notification-Request for Removal from the case-Therapist-EI Article 47 - Notification of Assignment of Professional Consultant Parent Request for Early/Late Hours of EI Service Session Note -Imp. Steps-Effective 09-01-24 Session Note Instructions Service Log-In Person & Tele -IS-Effective 09-01-24 Service Log -In-Person & Tele-Imp. Steps-2025 NYC EIP-Session Note & Instructions-07-29-2024-Fillable NYC EIP -Service Log-07-29-24-Fillable Session Note -Imp. Steps-Effective 09-01-24-ABA
	Increase/Decrease/Termination Request for additional Evaluation

Please click on a link below to download a form.

• Co-Visit Session Note-EI   (Instructions)

Session Note -Imp. Steps-Effective 09-01-24-ABA Daily Data Collection Form Daily Maintenance Graph Daily Mand Graph Weekly Cumulative Mand Graph Mand Frequency Data Sheet Anecdotal Data Preference Assessment Probe Data Sheet Verbal Inventory Maintenance Inventory List ABC Behavior Monitoring Provider Progress Note Page ABA Program - Cover page

Long Island EIP Division

Suffolk-Session Note-11-2024-IS Service Log -LIEIP-Imp. Steps-11-2024 Nassau-Session Note-11-2024-IS Nassau IFSP Admendment form Early Intervention Weekly Confirmation of Services- Service Delivery Log

NYSDOH - OPWDD - Notification of Potential Eligibility Insurance Tool Kit for Service Coordinators Insurance Tool Kit - Fillable Forms Resource Guide for Families of Children with Disabilities or Developmental Delays

Therapy Monthly Log SI ABA (2019)

• Consent for Evaluation and Screeing
• Reason for Delay-Evaluations
• Cover Page Evaluation Package
• MDE Summary 10 points effective
• EIP Referral Form
• Closure Form NYCEIP effective
• Release to receive EI from DOE employee
• Attestation for CPT Codes Evaluation EI

• WCDOH Bureau of EI Service Log- (Fillable) Revised -2025
• WC Bureau of EI Session Note ( Home Facility) with Instructions- 9-1-2024
• WCDOH -Session Note--Imp. Steps-Effective 09-01-24-ABA
• WCDOH -Session Note--Imp. Steps-Effective 09-01-24

The following is a list of documents that must be submittend to Important Steps, Inc. in order to receive Home-Based Early Intervention cases.

Please click on the links bellow to download the forms that must be filled out and sent or faxed to us.

For W-2 Employees of Important Steps, Inc. please send or fax the following:

• License/Certification
• Registration
• Malpractice Insurance (Minimum $ 1 million)
• I-9 Form "Immigration and Naturalization" Service
• Copy of Passport or birth certificate or alien resident card
• Resume
• Policy & Procedures Agreement
• Signed Appropriate Job Description
• State Central Register Clearance Form For Child Abuse
• Copy of Photo ID
• Copy of SS#
• Orientation Checklist
• Confidentiality Attachment
• Physical Exam
• 3 References
• Application for Employment
• Recomended Vaccinations
• Immunization Chart
• Criminal Record Information Form
• Drug/Alcohol Abuse Disclaimer
• In-Service Education Program Form
• W-4 2024
• Therapist Information Form
• Orientation Checklist for EI
• Notification to NYCDOH-DOE Employee waiver
• Direct Deposit Enrollment Form