Maryland Online IFSP

I. Information about my Child's Development:
Eligibility

A. Health Information
B. Init Evaluation
B. Cont Evaluation
C. Eligibility

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Category

* Your child is eligible for early intervention services based upon the results of the evaluation process. Eligibility is based on the one category that is checked below: // REQ

At least 25% Developmental Delay

My child is eligible for early intervention services because my child is experiencing at least a 25% delay in one or more of the following areas. Check all that apply:

Adaptive

Cognitive

Communication

Physical: Fine Motor

Physical: Gross Motor

Social-Emotional

Atypical Development or Behavior

My child is eligible for early intervention services because my child is demonstrating atypical development or behavior in one or more of the following developmental areas, that is likely to result in a subsequent delay. Check all that apply:

Adaptive

Cognitive

Communication

Physical: Fine Motor

Physical: Gross Motor

Social-Emotional

Diagnosed Physical or Mental Condition with High Probability of Developmental Delay

My child is eligible for early intervention services because my child has a diagnosed physical or mental condition that has a high probability of resulting in developmental delay. The list is not all-inclusive. Check all that apply:

Chromosomal disorders

Chromosomal disorders: Down Syndrome

Chromosomal disorders: Other

Chronic lung disease (CLD)

Congenital infection that is symptomatic (e.g. HIV)

Inborn errors of metabolism associated with CNS involvement (e.g. maple syrup urine disease and galactosemia)

Infants affected by intrauterine drug exposure requiring treatment or showing evidence of intrauterine growth restriction

Infants showing significant effects of maternal prenatal alcohol abuse (e.g Fetal Alchohol Syndrome)

Intraventricular hemorrhage - Grades III or IV

Poisoning, with a lead level of 20 ug/dl or greater

Moderate to severe encephalopathy resulting from insult to the brain

Neurodegenerative Disorders with onset in infancy and early childhood (e.g. adrenoleukodystrophy, TaySachs disease)

Periventricular Leukomalacia (PVL)

Prematurity with birth weight of less than 1200 grams (2 lbs. 10 oz.)

Seizure disorder where seizures are frequent or difficult to control or the underlying condition is associated with frequent cognitive impairement (e.g. infantile spasms)

Sensory Impairments

Sensory Impairments: Blind or visually impaired

Sensory Impairments: Deaf or hard of hearing

Severe congenital malformations (e.g. meningomyelocele and congenital hydrocephalus)

Surgical Necrotizing Entercolitis (NEC)

Other

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I. Information about my Child's Development: Eligibility

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I. Information about my Child's Development:
Eligibility

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