Date:
Name of Child: DOB:
Our records indicate that one of the following has occurred regarding your participation with
the Early Intervention – Babies Can’t Wait (BCW) Program:
Initial attempts to reach you to schedule an intake appointment have failed.
You have missed a scheduled intake appointment and attempts to reach you have
failed. Date(s):
After our initial intake meeting, our attempts to reach you regarding scheduling an
evaluation appointment have failed.
You have missed a scheduled appointment for the developmental evaluation and
attempts to reach you have failed. Date(s):
You have missed a scheduled appointment for the Individualized Family Service Plan
(IFSP) Meeting and attempts to reach you have failed. Date(s):
x Your child is enrolled in Babies Can’t Wait and attempts to reach you have failed.
If we do not hear from you, this letter will serve as your notice for closure. If you want to
continue with BCW services, please contact your Intake/Service Coordinator no later than
(Seven days) at the numbers listed below, or your child’s record/referral will be
closed.
NOTE: If at any time before your child's 3rd birthday you decide you want to reopen your
record/referral, please call the BCW office.
Sincerely,
Intake/Service Coordinator: Chari Sutherland
Phone:
BCW Office Phone: 770-535-5960
DPH/BCW No Contact Letter FINAL 09272017 Previous versions should NOT be used
DISCHARGE SUMMARY
Name of Child: DOB:
Deactivation or Transfer Date:
Completion of IFSP
Child exiting prior to turning age three due to no longer needing services
Moved out of state
Children who moved out of state before their third birthday
Moved to another district ( District)
Parent not interested
Children under the age of three whose parents declined all services (including service coordination services)
after an IFSP was in place or declined to consent to Part C services on the IFSP and provided written or verbal
indication of withdrawal from Part C services
Child deceased
Unable to contact/locate
Children for whom Part C personnel have been unable to provide early intervention services either due to lack ✔
of response from the parent/family, or inability to contact or locate the family or child after repeated,
documented attempts
Transition to Part B (list school system )
Children who were determined to be eligible for Part B. This includes children who receive Part B services in
conjunction with Head Start
Part B eligibility in process
Children who reached third birthday who were referred for Part B evaluation, but for whom the eligibility
determination has not yet been made or reported
Parent refused Part B referral
Children who reached age 3 and parent chose not to be referred to Part B
Part B ineligible exit to other
Children who reached age three who were evaluated and determined not eligible for Part B and were
referred to other programs such as Head Start (but not receiving Part B services), child care centers,
preschool learning center
Part B ineligible exit w/o referral
Children who reached age three, were evaluated and determined not eligible for Part B services and were not
referred to other programs
Parent withdrawn /FCP
Parent is declining participation in Part C due to their Family Cost Participation
Service Coordinator: Chari Sutherland Date:
DPH/BCW DISCHARGE SUMMARY FINAL 09282017 Previous versions should NOT be used