2021-10-0712:54

:#i*Sch Lki Nb.

Piedmont Healthcare 7065521801 >> 7063671142

/_\

i3esjenn|L#i#R°#:Pft¥S2j£]?#£#aleTGtsgiva006) 552-1700. Fax: (706) 552-17¢4',„ i`

I Chu, M.D.-DEAN®.re_ aAHTth°:eF4:2?LrmL±::±J. Patrlck Monfron, ALD.GA Lb. N6. i8776`. BEA fty. aue4aceBa

KAthedn®

• .^\ ;

• . ` Giena xp6Xch in.D.a-'3,

No. es4eio . DE4'Nb.

;in-Refer tz> C>T- fr oval + drednnd'ac+

Dx=RG2.a

REF,urfuLABELCONrrENTS +i.i.'! .`(, *... •givi. A --.. + ~ i!-i.-.J' :

Initial Evaluation (OT) -Chappell, Dalton 09/02/2021 -Parekh Famsworth, Stephanie -MS, OTR/L

Chappell, Dalton

Mitegtone PsdiaifeS Therapy Ser¥iee§510 Panther BriveJeifers®nS SA 3$549p: fas-as?-ii4i F: ?Sfu3&7-1142

-|9`((a(| Sc)`(i

Gender:

Date:

Address:

Clty, ST ZIP:

Contact Person :

Payer lD #:

Start of Care Date:

Diagnoses: lcD 10

M

09/02/2021

175 Cabin Creek Rd

athens GA 30605

Self

222118752259

09/02/2021

Time ln / Out:

DOB:

Provider:

Location:

Physlclan:

Treating Therapl§t:

Plan of CareEffective:

02:30 pin -03:30 pin

07/15/2021

Milestone Pediatric Therapy Services, lnc.

Telehealth -02

BLACKMON, KATHERINE

Parekh Famsworth, Stephanie -MS, OTFVL

09/02/2021 -03/02/2022

Code Onset Diagnosis

R62.O Delayed milestone in childhood

Peabody Developmental Ivlotor Scales€econd Edition (PDMS-2)

The Peabady Developmental Motor Scales-Second Edition (PDMS-2) assesses fine and gross motor skills in children from birth through5 years of age across six subtests: Reflexes, Stationary, Locomotion, Object Manipulation, Grasping, and Visual-Motor Integration.Subtests are combined to yield three composite scores: a Fine Motor Quotient, Gross Motor Quotient, and a Total Motor Quotient.

Subtest Scores

Percentll® Rank Standard Score

Grasping (Cr) 25% 16

Visual-Motor lnt. rvi) 16% 9

Summary

Dalton is a 1 month old boy who was born full term for scoring purposes on the PDMS-2. Mom reported that Dalton has difficulty feedingfrom a bottle with continued reflux after feedings that has been severe enough to warrant a hospital visit in August due to difficultybreathing after severe reflux episode. Dalton has now been referred to pediatric gastroenterologist and has low white blood cell countper mom report of bloodwork done in hospital. Dalton now has rice cereal added to bottles and demonstrated good lip closure around

Created with Fusion Web Clinic

-Ei~!EiL- -_

Paoe 1

Initial Evaluation (OT) -Chappell, Dalton 09/02/2021 -Parekh Famsworth, Stephanie -MS, OTR/L

bottle. Mom reports that Dalton has difficulty tracking objects at close range and does not yet turn for sounds. Dalton has been referredto Babies Can't Wait due to concerns regarding feeding skills. The Peabody Developmental Motor Scales, 2nd Edition (PDMS-2) is anormative based assessment, which is comprised of six subtests to measure gross and fine motor skills. Due to currentrecommendations based on Covid-19 outbreak, testing using tlie PDMS utilizes tele-therapy with objects Of convenience that familyalready owns and parent report and is not considered to be standardized. Dalton.s evaluation was conducted in his home with his mompresent. Mom reported that Dalton is able to grasp when objects are placed in his hands and does not yet visually track objects. Due toage, delays based on age are not severe diie to few qualifying expectations of development. Due to infomed clinical opinion based onfeeding concerns and tone noted in video session as well as impacted self-care skills for age appropriate ADL Of facilitated feedingsuccess as well as conference to review results on the AEPS conducted by speclal Instructor, Brencla Bush, early intervention servicesare recommended with PSP to be chosen at bi-monthly team meeting address deficits in skills for fine-motor skills to improveparticipation in activities Of daily living.

Planned lnterventions

Billing Codes

Code Description

97166 OCCUPATIONAL THERAPY EVALUATION- MEDIUM

97530 Therapeutic activities to improve function, with one®n®ne contact between patient and provider

Frequency / Duration

Visit Frequency 1 x/Month

Therapy Duration 6 Months

Effective Range (plan Of Care) 09/02/2021 -03/02/2022

Signatures

'.prrfuaftdstgrhi{L*

ElectronicallySigned On:09/02/2021

Th®rapiet: Parekh Farnsworth, Stephanie -MS, OTFVLState Lic®ns® #: OT007051

Created with Fusion Web Clinic

1q\(orlsc"\Y

Page 2

plan of care (OT) -Chappell, Dalton 09/02/2021 -Parekh Farnsworth, Stephanie -MS, OTR/L

Chappell, Dalton

Milestone PediatriS Therapy Sgr¥ises51 S Panther DriveJgifer§ens SA as549p: 7$8~as7-ii4i F: 7as-387-ii48

Gender:

Date:

Address:

City, ST ZIP:

Contact Person :

Payer lD #:

Start of Care Date:

Diagnoses: ICD 10

M

09/02/2021

175 Cabin Creek Rd

athens GA 30605

Self

222118752259

09/02/2021

Time ln / Out:

BOB:

Provider:

Location:

Physician:

Treating Therapist:

Plan of CareEffective:

02:30 pin - 03:30 pin

07/15/2021

Milestone Pediatric Therapy Services, I nc.

Telehealth - 02

BLACKMON, KATHERINE

Parekh Famsworth, Stephanie -MS, OTR/L

09/02/2021 -03/02/2022

|"o\15o„YCode Onset Diagnosis

R62.0 Delayed milestone in childhood

Summary

Dalton is a 1 month old boy who was born full term for Scoring purposes on the PDMS-2. Mom reported that Dalton has difficulty feedingfrom a bottle with continued reflux after feedings that has been severe enough to warrant a hospital visit in August dlle to difficultybreathing after severe reflux episode. Dalton has now been referred to pediatric gastroenterologist and has low white blond cell countper mom report of bloodwork done in hospital. Dalton now has rice cereal added to bottles and demonstrated good lip closure aroundbottle. Mom reports that Dalton has difficulty tracking objects at close range and does not yet turn for sounds. Dalton has been referredto Babies Can't Wait due to concerns regarding feeding skills. The Peabody Developmental Motor Scales, 2nd Edition (PDMS-2) is anormative based assessment, which is comprised of six subtest§ to measure gross and fine motor skills. Due to currentrecommendations based on Covid-19 outbreak, testing using the PDMS utilizes tele-therapy with objects of convenience that familyalready owns and parent report and is not considered to be standardized. Dalton's evaluation was conducted in his home with his mompresent. Mom reported that Dalton is able to grasp when objects are placed in his hands and does not yet visually track objects. Due toage, delays based on age are not severe due to few qualifying expectations of development. Due to informed clinical opinion based onfeeding concerns and tone noted in video session as well as impacted self-care skills for age appropriate ADL of facilitated feedingsuccess as well as conference to review results on the AEPS conducted by special instructor, Brenda Bush, early intervention servicesare recommended with PSP to be chosen at bi-monthly team meeting address deficits in skills for fine-motor skills to improveparticipation in activities of daily living.

Planned lnterventions

Billing Codes

Created with Fusion Web Clinic Page 1

2021-10-0519=58

enREi 18:17:29 EDT

Piedmont Hea[thcare 7065521801 >> 7063671142 P 4/4

TO: i7esse2i7Oi Pcae: se From: thebel fflling sewicaa Fax: 8557041€11

Plan of care {OT) -Chappen, Dalton Oor02/20Z1.:Parem Famsworth, 3tophanle -MS, OTRIL

Code Deecrip(i®rL

9?166 OCCuPATI ONAL THERAPY EMAluATlohL MEDl uM

97630 Therap®utlcactfvftostofroprovefuncth,wlthoneenenecontactbetwdypetientendpfovider

Frogtiency / Durathn

vlelt Froquoney 1whonth

Tharany Bgmth 6 hfrode

Enecaro Ftwg® a" Of Can| ~- , ' , , . , , *

Slgnafum8

C®rtlfieatleyi of «ctdeal et®oeeerty: It wll be underfud ust the debent plgn carob oboro ts certrm medtoally "soescary by de

faatg#d#ra»a;[thpherysplerer:rmtry®fro¥#,inactth::#caifenaL#n%#¢jcpralr##fa8n9{3d*Pui:tr¥at##:|#de#a#a#penden"

Q#fiat-f* gg#fREItft^p

Thonplev Paroth Famswoth, StophanieMS.OTRfuSlat. Lie.Ira. #: OTcO7051

_ifa±r{+ a _ i+ ur> I,.____~be ±=±=±±Physiferi: BLACKMON. KATHERINENP]: 1801093471

Cleated with Fucton Wet Clin.ro

1 ? \ \6115'J ` ) L7

Peg® 2

Plan of care (OT) -Chappell, Dalton 09/02/2021 -Parekh Farnsworth, Stephanie -MS, OTR/L

Code Description

97166 OCCUPATIONAL THERAPY EVALUATION- MEDIUM

97530 Therapeutic activities to improve function, with one®n®ne contact between patient and provider

Frequency / Duration

visit Frequency 1x/Month

Therapy Duration 6 Months

Effective Range (Plan of Care) 09/02/2021 -03/02/2022

Signatures

Certification of Medlcal Necessity: lt will be understood that the treatment plan stated above is certified medically necessary by thetreating clinician and physician mentioned in this document. Unless the physician indicates otherwise through written correspondencewith our office, all further prescriptions will act as a certification of medical necessity on the treatment plan indicated above.

f ife,tiS&f*

i*f tEL##_ g#,mo%dz32n;

Th®raplst: Parekh Farnsworth, Stephanie -MS, OTR/LState License #: OT007051

Electronically

Physician: BLACKMON, KATHERINENPI: 1801093471

Created with Fusion Web Clinic Page 2

Babies Can.I Wait Early Intervention Program

GEORGIA DEPARTMENT OF PUBLIC HEALTH

District: 10ro Northeast Health District (Athens)

Individualized Family Service Plan (lFSP)Meeting Date: 9/24/2021

Initial lFSP Date: 9/24/2021

lFSP Type: Initial

Section la: CHILD INFORMATIONChild's Legal Name Date of Birth Gender

Dalton Chappell 7/15/2021 E Male I FemaleArm Name Child lD County

AT1000148627 Clarke

Language I nterpreter Needed FC P%

No0%

Race

I American Indian orAlaska Native E Asian E BlackorAfricanAmerican

H Native Hawaiian orotherpacific Islander H WhiteEthnicfty

Hispanic/Latino? No

Section lb: FAMILY CONTACT INFORMATIONPrimary Contact Name Relationship to child:

Takelia Chappell Mother

Plione Language In(erpreter Needed

706-255-1838 English No

Physical Address

175 Cabin Creek Rd ATHENS GA 30605

Mailing Address

175 Cabin Creek Rd ATHENS GA 30605

Section lc: BCW CONTACT INFORMATIONService Coord inator Ageney Name

Sarah Hall SARAHRHALL LLCEmall Phone Fax

sarahrhallbcw@gmail.com 706-765"64Address

202 Ben Burton Cir BOGART GA 30622Primary Provider Ageney Name

Sarah Hall SARAHRHALL LLCEmail Phone Fax

sarahrhallbcw@gmail.com 706-765-8464

Page 1 Of 7

Chjld's Name: Dalton chappell Date of Birth: 7/15/2021

Section 2: FAMILY ASSESSMENTI choose to share information about my concerns, priorities and resources and/or include this information in the lFSP. Iunderstand that if my child is eligible, he/she can still receive services if I do not complete this section. Family Permission?

E Yes I No Date: 8/18/2o21

Section 2a: All ABOUT OUR CHILD AND FAMILYWhat family strengths are helpful in suppohing your child? Maternal grandmother, and the childrens' godmothers help. Daddoes not live with family, but is very involved in their lives.

Where do you go when you need help? family

Tell me about your priorities and concerns related to your child's growth and development. feeding and prematurity

Section 2b: IDENTIFICATION OF NATURAL ENVIRONMENTS(S)Where does your child spend time (at home, community, neighborhood, childcare, etc)?at home

With whom does your child spend time (immediate family members, relatives, neighbors, friends, child care providers, etc.)?How often/how much time (include day/evening/weekend and frequency)? familyTell me about the most difficult time of the day for you and your child. feeding -he has a hard time latching on to the bottleand spits up frequently

Section 2c: CHILD CARENo Information ls available at this time

Section 3: HEALTH & MEDICALv,`, ,;,,; :.::'; ,,I:,:,.:'-,,,`,' ' ',':` /,, `:,``:;;;`' I ,:,:i,::;,. ,;;,,;::: :,+, I,:;-. :.;,,,:I::-r

l, ,-,`., ,,` ,,`-,y ,.,(`,,:i,,r `,(,;,`,-^,`~`.'"-\,,`J,.\,`.,'..,,I," ,`,'-,\-=,Y-,, ,, ,, ,?(,-,,.I `,,?, ,i-,,,f,,, ,, ,\,.`, i^('-:,i, , -:'\--),; ,-_,:` .,. ,.'f :`-'-<:'' ``. ,:`-, :`'`< 1 . : ., ...; i :'-`t , ;,i,. ;,

J/,,A E:`/1`,) ),(' ,,``f,,|ty;-,,,, , ,J^-I-J,, , `, J\(I ,-,},\^`\c,-`\ ' <\ I)\ ,I,`'' ` ``'` Z`^/;/4l)`~'`"( , `'¥'<`\,";`,,\:_` `\/\+`\`^/I,:\_`.\ \t/`}'Y'` '^ ,Jl(`,\`t¥ 1` /1; ,.L\u /;)/t^)_) 'r/ •,, , `, ,i-< `*'''<,I

Birth History per mom: Dalton was born at Emory Decatur Hospital - Mom's water broke while she was at work at Emory.Mom's pregnancy was high risk due to her asthma. When she was 8 weeks pregnant, she had a hematoma develop on tother side of the uterus wall, and she had bleeding for 10 weeks when it healed itself. At22/23 weeks she was DX with apelvis condition (her pelvis began the separation process early). She was DX with preterm labor and was given steroids tohelp his lungs develop. She was on bed rest and then required PT> He water broke and was in labor for 3 days and thenhad a c+section. He was in the NIC for one day not breathing correcilly and jaundice. He was on IV, breathing tube andfeeding tube. He stayed in the warmer for 34 days. He had high blood sugar day after delivery.

Section 3a: GENERAL HEALTH & DIAGNOSIS

--`_I,``:, .,•,;;:.,I,;i,-i;/,:;.'-`,::`.-,,;,`.-I,`.,.-;:`'-.,;-./'J:- ,, -J ;,: :'',,,,, ,, :,,,,

I

-, < ,,,,1->t, ` ,,,L^` ,`

No R62.50 10 Unsp lack of expected normal physiol devin 9/2/2021childhood

Section 3b: REASONS FOR ELIGIBILITY;;::,I:., ,::;.i.::;,,,c:: : ;-:., '.`.; , : ,,:;; ,:i,;,:,i:,: , : ' ::,',i,;,;, ':: .,:-.:', :,,:.

'1111111111111111111111111111111111111111111111111111111111'1-̀'(J,-,l:.;. '`.,,:I,r,`,-`\.,,,,, .. .:. t \-, , \. -.>, " y. i, +, :uation,andProgrammingSystem

The multidisciplinary team reached a consensus of eligibility using the Assessment,for Infants and Children, Second Edition. the Peabody Developmental Motor Scales. Se Edition, parent interview(s),and a review of medical records and found Dalton Chappell eligible based on informe inical opinion in fine motor areas.

I _ ` )L.>,'l >` ,-, , ,, .-

i-) .;;,,, ,1 /.,;,I -i),,: I,,,\ -

:-i(`:,> `-` ,,,),,/ -T,,{ \, ``-,-,,,;,., -\l`„-``L/,/-„ -.,, ,``.,,`.,,.,,,,i(\,t -( -`\. \-,"(-J )/-/. , - <,, -- • `'-,,,< -,,,( -;i,, ,`:.:1.i-,,^`„„ `J`,\ ,,\,,--i,`>.,,,l'' -

ICD Code |lcD Rev# |Diagnosis Description

No Information ls available at this time

Page 2 Of 7

Child's Name: Dalton chappell Date of Birth: 7/15/2021`..i,,:,,J.:;.-,:..,'.`,i,:,:':,,'..,.`,J,:.,:,r,:/".i.^--,`:,;A;,,,-I,,(-:;I,:,-,,`r`:,`-:,-(``+-),,,`-\,/-,,,--,`;,,,-:,1,`,,',J"::/I-:,,-`'.,

Significant Delay in Development ( 2 Standard Deviations)

E Cognitive I Communication I Adaptive I Rho¥:jrijj;Porno,Sa/eF:i:g) H sociavEmotionaiModerate Delay in Development ( 1.5 Standard Deviations)

I Cognitive I Communication I Adaptive I #¥:iijj;For:,SHSH/eF::i:g) I Social/EmotionalICO Delay in Development

I Cognitive H Communication E Adaptive H #o¥:i;+i:for:,Sa/eF::i:g) H sociavEmotionaiSection 3c: PHYSICIANS

; / , `;I, ,/-`' ,-:, ,,-`-,,r :,-`' `-,}-:::i ,--, ,:I•,i,J;I:,-I, :, , . `-.-,,7-,J,i,`'`'_:,'-.{,IA, r//,

`:t, ,)'`r i`,I,``'r:z\'')'`dy\ `\,`'`3,\;(,"\ \ `' I I S' , \~z`' • ie`'\J-\,,A+ \`,\, ,,y,,J+,,,\``).,`,. `y"\( Jl,,\ `\\ , ````\` ,,`,\`"\\

I IName: Dr. Katherine Blackmon Phone:

1305 Jennings Mill Road Suite 230 WATKINSVILLE GA 30677I,, \\:\``\/I .;,`\.r,,.<`:;,,, , 1 . y `\;\±,`,>? , z\ /) ,> , L.,,I t,,r\,``,;r,,\\`:i,){:'£,<y,`,,\, ,~L:``_\z` ,`,, (i,z`( `z>',\ t<vc , \\\ r``(.,`,,\ '\`;," ^'t,¥,{ \'`,I;\(``.}\'`M`\.r` ,``,I`S`i:t-±.`b±±a``±:it±`L.I.'\'::`);,'?':r::\t1;'):``'`,I;::I:\`\`\t',,`t`i`!`\,,:`^`\\,'::\t,\`;''::``v`/`,.,``.\,:`,`.-r,'`+\;^``„v:`,:.`,,:i`,tr,/-,:,

//.`1 I,`:,:,,v`^\rt.,`w/.::: I:`pr\" L:; " \\(^! ,:\! :I, ,,,` r`/:' I,T;``.v ` ` `\:..::, /*," :'` tlt-'! ,._:`, "` I:t{,I"':~+ -'tts-'`l;':jr§`/l ,'''`c``: 1` -.) ,+ :;,fL\'Li:`J_\``J ``J.`:tl-` :i.,I-:,:I,I/ `_v, „ ,I -,.i -,"`,.:`, ,-::,`,`/ /(,`(`. , ,/)1., .\:. , `,:I,.,'/:,:.-,I,,`J' ,i , `:,.`-.,:(1,,'\t);.;,\,

No information ls available at this time

Section 3d: VISION & HEARINGI I

' ,r: :'-,`,,', '

Child has had a hearing screening I Yes ra No Childhashadavisiontest H Yes E] No

Has the child passed the Newborn Hearing Screening?

I Yes Ed No I UnknownNewborn I Pass Newborn I PassLeftEar I Refer RightEar I Refer

Parent/Caregiver Concerns Parent/Caregiver Concern

Dalton also failed the second attempt and has a follow upscheduled with UGA speech and hearing clinic.9/24/2021 At follow up hearing, he did not pass the lowsounds. He has been referred to an ENT for congestion andfurther evaluaiton

Section 3e: ASD Screening and EvaluationChild ls under 16 months of age and has no screening or evaluation information

Section 4: PRESENT LEVELS OF DEVELOPMENT lN DAILY ROUTINES & ACTIVITIESRoutine : Bathtl in a

Task difficulty: I Easy H Some problems ra Difficult

Developmental I Cognitive H Communication H Adaptive E physical (Gross/Fine I Social/Emotionaldomains: Motor, Vision,

Hearing)What's working well: tolerates it if quick

What's not working well: he does not like his hair to be washed. Does not like the noise of the water or when it splashes onhis body

Page 3 of 7

Child's Name: Dalton chappell Date of Birth: 7/15/2021

Page 4 Of 7

Child's Name: Dalton chappell Date of Birth: 7/15/2021

Routine: Wake-up

Task difficulty: I Easy a Some problems E Difficult

Developmental E Cognitive H Communication E] Adaptive EJ physical (Gross/Fine I Social/Emotionaldomains: Motor, Vision,

Hearing)What's working well: Mom has about 3-5 minutes after he wakes to prepare his bottle

What's not working well: He is cranky when he wakes up and ready to eat

Section 5: OuTCOMESi. .` ,,r`{\-` ,, ,(:,,-,.`i,, ,-.,, ,,,i/(/,.(,., ',I./ ,i"' `

`<`\I

'/,' --'J;,i1,_,:\:r;-,\`,!`.+.A .:~"

'I

". ,J^.'`'-i``f . !r^. -,/. I

Family will be connected to deve]opmental and community supports as needed based on family needs. Family willparticipate in Physical Therapy evaluation

Strategies and ActivitiesSC and family will be in regular contact regarding progress and concerns. SC wilI facilitate the transition process. SCwill request Physical TheraDv evaluation

How does the team plan on measuring progress? When will progress toward the outcome be measured?

E Provider progress Notes H EachweekEI Parent Report H Monthly

E Service ccordinator with family E 6monthreview

Section 6: BOW SERVICES & SUPPORTSI ". ,I. .,`-;; ,-v--,I';x,

-:I,-;.,,,, r I,3"` ~,:\',I,:.i,(, :-; (--<.,1.,`.t,J;\,(.-:."

-;`\',.J.,:'`.;'',r,,-,:,'i;,,;/-,I,,?',,I`.,,,'ul-:,\\-;,,,,:,,i:`,,,,`t,`\'`,<-:,I,),

( ,y' ' + (, ,,i-1"`,`,~.•,` I,(I

('``: \\. ,\, ;,/`,-`\.,``r '\' ``,,;\:'`f :, +,:.lky,1,,,,1 ```,,•.,i-..),-,,,`,\.i,``:,i-`:,<`,I-I,-.,/:`_.,

\ \, ,„§srvi?6! FgrHS,'/:,,8ifetbgiv,u ` ,, \, ` 1 •(.1,urat'qr*.?+FJ ' ,I, . :r:i. ,,7!rx`|,` .,ti `,( ,-i, ,,/ I

-.'m-pe-CT'-*"I.I

ervice Coordination Home 1 Per AuthOMin arah Hall BCW 8/18/2021- T2003Intake Coordination 6 9/4/2021

pecial Instruction Home 1 Per AuthOMin Brenda Bush Bow 8/18/2021- T2003valuation/Assessment 6 10/2/2021ccupational Therapy Home 16 Per Auth0Min Stephanie Parekh PS 8/18/2021-ligibility Detemination Evaluation Famsworth 10/2/2021ervice Coordination 1 Home 6 Per AuthOMin Sarah Hall Bow 9/24/2021- T2022ace-TCLFace Visit plus 3 ancillaries 9/23/2022hysical Therapy Home 16 Per AuthOMin ania Avolio PS 9/24/2021-valuation/Assessment 12/4/2021

Primary setting for services (Most services occur here): Home

Section 7: NATURAL ENVIRONMENT JuSTIFICATIONNo infomation ls available at this tlm®

Section 8: OTH.ER SERVICES & SuPPORTSNo information is available at this time

Section 9a: TRANSITIONI:;,: : : ,';`'' ; y, :,;-,, ,(:, ,; , ':,:_, :_,, -_.,::y::J,

1111_:I `` VJJ ,, ``-•,`=y`,.,v:==,f,;(,'`I-,-`:,,JJ!-l`:,,',/,,:,.J;r'='(,._-,,.,.`-.",/y','_'`'-- •:I `,,: .`\,I,: ;`

\,/`,,:',, T L`.,,1 \'.I--,,.I).``X.

•ii=i`,|_-,:3_.\ii``,,,-` -'\,-,.I ,, , ' -l,i/`,i-;,,;~+'.\±Jr _`,",.--ir!J` -J`-vi,I,,,,,,l,-',(, ,\"-,Ji<,-:J /i

y./ , :,(``,`?\,,I,,,,;`;:!,\, , ( ,z-,,,`-i,,1' ,/, ,•:-,.,,,,`,~%;\,,,,,,'\:;i,-(:,,,:,'y.,)/,.``J,,(J,:,`,-``..~,,;;`.: ,, ,, -( , ' ` , ,;rj . , -.. - .

•1 /,-,,, -.fl:r,`-,,.`l, :(11. /-,,',,', ,h,' ;, ;

Ongoing discussion with and training Of, Discussed transitio process from BCW at 9/24/2021 SCparents regarding future placements age 3 and how BC 11 help facilitate thatCes.and other matters related to the ch ild's process into other stransition'<`,:,,,J.:..:: -::::,,,:,,,:., :. , :, :. I. ::,,:.:,i ;;.:,:,::,:;,::,;,:,:i : :::,,;I:;, :,:a,:.,:

:` ul.\-,

1

`!`,`1,,,.I_,(,,)I -I `^ ---, |y`,, ,

1 '': Tr `f '"`^+,-`V,>.i,_A =i( ,"i(/I ``' <,r`i` .(A,- r`i.`tr`:\;.) A,`` '\:| ,,|v;I lr`l I I ```r\rJ*„H / r:),L, \ )`~? \,, , /,"r,

: ,-`:-i.`L,,`,>' , ). I ",`

I I:\r-.-,-I.,,, i-I i ,,"/,V,(, ,,. . :.'.S',--i,

•1" , S+ ,`\,--',; :,/\;,-.-` ,--1.'^1,--`=`\:, ,i-_^' .:,y` ,A ,,,`*,>', ,).++, -(` -\ II ' I +',` I,-JI' \

:,,,-.,7,,:<:,` // ,;` : `r ',`,~`;J,y,`: `` (-( -: J-\:fl, ',,i i..:a.. =i',,,,-i (' /,J , `,:`, -:`,,`,3-\ -:'--, ,:,,,•` '``, ,-, \ .-

-,r\`',\`,.i?.`i,-¥:/II.:;-;, +;:\ '..,`,,,;/, i : I I ,' i `., ,

--=< ,, i1',, `' :` ``-/:,^1,, -`/-i\-,,-,

``, \``-:`,\\, /r,-,

'`.+ •L / '),. i -\:i:/_, ;-; .,, :,

Page 5 Of 7

Child's Name: Dalton chappell Date of Birth: 7/15/2021

)J 'y' /,/,-

^`^

y

7,, \3

¢,._

t

:*ii *L:-it,.fil Zst\ i-<

**-,C ./ \` `J` ,,,-\

\\,`, ,<_` I

I,ti,,,\- ,-`-,€.vr1<•,j\c;y,i,/,

`,, A /,, ,\)'`,fe`

•\ `` I.., -t`J .

<-,r IA,,,

( J!y

- / ` I,,1\

- r,.i-:, if,

I ,," -,`-'' ,1•<``!, }

-,< :,, ,`, yt*>\,(,,`-:,-^,,\,,

Section 9b: TRANSITION PLANNo information is available at this time

Section 10: lFSP DEVELOPMENT TEAM & CONTRlBUTORS`,`;i:-<., ),

',,:,,:5J,,;-)'`,^'`JL

s`,,`.'~`,4',-,-".-

I,i-',,,,1

``,. ,

i/,i

`,,i, ```-`!

`;`` I ; `-- , /'\,,. .,.I ;, '•,/,J(

\i?.

Takelia Chappell Parent or Guardian Telehealth

Sarah Hall SARAHRHALL LLC Service Coordinator Telehealth

Brenda Bush Brenda Ann Bush Evaluator Telehealth

Stephanie ParekhFarnsworth Milestone Pediatric Therapy Services, Inc Evaluator Telehealth

Section 11 : PARENTAL SIGNATUREParental Consent for Provision of Early Intervention Services: I have had my parental rights reviewed with me, bothverbally and in writing. understand all service providers chosen by me to implement this lFSP, including Bow, will shareinformation, both vchild/familytoreceierbally and in writvetheservicesliing, only to the extent it relates to the implementation of the lFSP. I give consent for mystedinthislFSP."Consent"meansIhavebeenfullyinformedofallinformationabout

the activity(s) for which consent is sought in my native language or other mode of communication; I understand and agree inwritingtothecarryingoutoftheactivity(s)forwhichconsentissought;theconsentdescribesactivity(s)andlistsanyrecords

which will be released and to whom; and the granting of my consent is voluntary and may be revoked in writing at any time.lnaddition,ImaydeclineaserviceorServiceswithoutriskingthereceiptofanyotherearlyinterventionservice(s)underBCW.

Parent:Dalto.. I I

Parent:D aha.. I I

Funding Source Legend for abbreviations shown in Section 6: BCW SiRVICES & SuPPORTSI) , /, \.\fe\/l ,,4 \. ri\ /l , /`

( , ,may a ar'\,;` \̀ `¢s`:prpt,&n ,,,/,`/ ,\,y,(+ ,|`^i -`-`*,.. .,/`,(,`\.`\.

INS Private InsurancePCK/A Peachcare for Kids -AmerigroupPCK/CS Peachcare for Kids - CaresourcePCK/PS Peachcare for Kids - Peach StatePCKAVC Peachcare for Kids - Well CareA Amerigroup CMOCS Caresource CMOPS Peach State CMOWC Wellcare CMOPCK/FFS Peachcare for Kids - Fee For Service MedicaidM/FFS Traditional FFSAVFC Amerigroup 360 Foster CareKBAvl Katie Beckett - Children with Insurance

Page 6 of 7

Child's Name: Dalton Chappell

KBAVol Katie Beckett - Children without InsuranceAA/FFS Adoption Assistance - FFS Medicaid (CMS)RFTS Right from the StartKB/DW Katie Beckett (Deeming Waiver)SSI SslFC Foster CareFop Family Cost Participation

BCW Babies Can't Wait

Date of Birth: 7/15/2021

Page 7 Of 7

Doousign Envelope lD: 01 C97004-F53E4253no7F1 -5622DD34CD76

Child's Name: Dalton Chappel| DOB:7/15/2021

lFSP DeveIopment Team and Contributors

Name Agency Role

Method ofParticipation

SignatureTakelia Chappell parent Telehoalth ri#rLAndLSarah Hall SC Telehealth r=mtp'3'`Stephanie Parekh Farnsworth evaluator Te]ehealth farr=.w tl, f". t„,ul,Brenda Bush evaluator Teleriealth F=,,.

LunA£.in

Section 11: Parental Signature

Parental Consent for Provision of Early Intervention Services: I have had my parental rightsreviewed with me, both verbally and in writing. I understand all service providers chosen by meto implement this lFSP, including BCW; will share information, both verbally and in writing, onlyto the extent it relates to the implementation of the lFSP. I give consent for my child/family toreceive the services listed in this IFSP. "Consent" means I have been fully informed of allinformation about the activity(s) for which consent is sought in my native language or othermode of communication; I understand and agree in writing to the carrying out of the activity(s)for which consent is sought; the consent descries activity(s) and lists any records which will bereleased and to whom; and the granting of my consent if voluntary and maybe revoked inwriting at any time. In addition, I may decline a service or services without risking the receipt ofany other early intervention service(s) under BCW.

Parent: rtiF±iftry Date: 9t28;2o2i

Pa rent: Date: