a child 6

Executive Director

Stephen GiwdanDiitcnw

Cadi? CiuiEvuioDirector of Childimfc Services

Middle IslandLongwnod RoadP.O. Bos 12Middle Island, NYM9S3(63D924-OOOB Phone(63 1)924-1X43 Fax

Lindenhurst887 KeJJum Strtet

11757(631 (884-3000 Phone(631) 884-1959 Fax

Riverhead$56 East Main StreetRivemead, NY 11901(631) 369-1927 Phone(631)369-1937 Fax

William Floyd99 Lexington RoudShirley, NY 11967(631) 231-6800 Phone(631) 281-6096 Fax

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JUST KIDSEarly Childhood Learning Center

Consent for Evaluations

date

foster worker name child' s name

agency-

-fa/ gfW-

date of birth

address listrict

De ir fllS. Sfoster Corker's name

We have received consent from the school district toevtluate the above-mentioned child at our facility. Pleasesi .jn the enclosed consents for the individualized evaluationsan I fax-return to 924-4298.

In addition, as the foster parent/guardian will bebr. nging the child in for the evaluations, please sign thosest; tements below with which you agree:

I hereby give consent for the above referenced child'sfoster parent(s)/guardian(s) to be present for and participatein the child's evaluation at Just Kids. "

A L A- IJI hereby give consent for the above referenced child's

fos;er parent(s) /guardian(s) to receive a copy of the child'seva Luations.

Foster Work/Legal Guardian

I do not give consent for the above referenced child'sfos .er parents; (s)/guardian (s) to be present for andpar icipate in the child's evaluation at Just Kids.

(fos er.con) Foscer Worker/Legal Guardian

01/28/2010 14:35 631-345-21B5 PAGE 03/09

Service/SupportNone Required

Service/SupportNone Required

ilPartlcipatiott witb Age App^piriate.Peejissioccuirs only whence rt4ttaipe.iirsey^tity;.bfttie disability is suchtliat, even, with the' - • ' '

Explanation of the extent, if any, to.vhich the student will not participate in general education programs, includingextra curriculac and other nonacadcrnic activities!

In die areas of non-participation, the^student requires special instruction in an environment with a smaller student-to-teacherratio and minimal distractions in order to progress in achieving the learning standards,

Current functioning and individual needs in consideration of:• the results of the initial or most recent evaluation, the student's strengths, the concerns of the parents;• the student's needs related to communication, behavior, use of Braille., assistive technology, limited English proficiency;

and• how the student's disability affects participation in appropriate activities.

fiofr the Student's Disability Affects InvolVement and Projpsss PaMdpMoiti in Age Appropriate Activities;The student has a significant delay in speech skills and concept development, which interferes with participation in ageappropriate activities.

Academic Achtevenietit, $uflcti^Current levels of knowledge and development in subject and skill areas, including activities of daily living, level of intellectualfunctioning, adaptive behavior, expected rate of progress in acquiring skills and information and learning style.

Levels/AbilitiesWinona exhibits a significant delay in speech and language skills at this time. Winona is exhibiting delays in her nonverbaland verbal reasoning skills as well as in her general concept development Winona continues to have difficulty identifyingcolors and does not yet recognize letters of the alphabet.

NeedsWinona needs to improve overall speech and language skills. Winona needs to develop her cognitive and academic skills.

Standardized Test fcwultSiPate Test11 /06V2009 Peabody Developmental Motor Scales-2

Test <)f Visual-Motor Skills11/03/2009 Achenbach Child Behavior Checklist

Goldman Fristoc 2Khan-Lewis Phonological AnalysisPreschool Language Scale - 4

Vineland Adaptive Behavior Scalesilnterview Ed.

SubTest Score/TypeFine Motor Quotient 88Total <5SParent 54/TSTeacher 67TSSpeech Articulation 60Composite Score 49Auditory Comprehension 65Expressive Communication 64Total Language Score 61Communication Domain 65Daily Living Skills Domain 77Socialization Domain 79Motor Skills Domain 81Adaptive Behavior Composite 72

mnonaRPixcitellt page 2 ofS

Ml/28/2010 14:35 631-345-2165 ' - PAGE 04/09

Wechsler Preschool & Primary Scales of Intell.-III Verbal 67Performance 73Full Scale 69

The degree and quality of the student's relationships with peers and adults, feelings about self and social adjustment to schooland community environments.

Levels/AbilitiesWjnona presents with attentiona). difficulties and tendencies toward aggressive behavior. In the classroom, Winona requiresa fair amount of adult redirection in order to follow instructions and cairyout assigned tasks.

NeedsWinona needs to improve her relationships with peers and adults. She needs to develop her ability to follow instructions andattend to tasks.

Physical Development:

The degree or quality, of the student's motor and sensory development, health, vitality and physical skills or limitations thatpertain to the learning process.

Levels/AbilitiesWinona's physical levels and abilities are within age appropriate expectations.

NeedsThere are no physical or motor needs that should be addressed through special education, at this time.

Management:Needs; ' . • . • • • • • . ' : • : . - . " . " '•_:••-"•:'• ! . • • . ; • ' : • . • ' • :':• ;:'v . ' . . • • ' •". • ' .

The nature of and degree to which environment modifications and human or material resources are required to enable thestudent to benefit frorn. instruction. Management needs arc determined in accordance with the factors identified in the areas ofacademic achievement, functional performance and learning characteristics, social, development and physical development,

The student has significant delays and requires an intensive, small teacher-to-studcnt ratio program provided in a specialschool environment in order to academically progress.

Committee: Committee on Preschool Special Education Date: 11/20/2009Reason: Initial Eligibility Determination Meeting

Expected Grade: PreschoolAttendance: BrendaMcCabe, Chairperson; TomSipala, General Education Teacher; Ira Siegel, County Representative;

Barbara Gramello, Special Education Teacher; Brenda McCabe, Speech/Language Therapist; Lisa Carbone,Foster Mother; Paul Piscitelli, Additional Parent Member; Lori Goldstein, Facility Representative; LoriTownes, Case Manager

Comments: Current reports indicate that this student presently attending a preschool setting five full days weekly,demonstrates average daily living skills. The student is living in a foster home at (his time however, thefather is pursuing full custody. The evaluation process was initiated by the foster parent and Department ofSocial Services due to concerns with learning and language skills. The testing revealed significant delayswith expressive and receptive language skills. Further, delays with concept development impact overalllearning. It is felt that the student is eligible for special education services. Recommendation, is forclassification as a Preschooler With A Disability and placement in an 18:2:1 roll day special class withspeech three times individually. The foster parent, father, and DSS Caseworker are in agreement.

Based Upon: Social History, 11/20/2009Psychological. Evaluation, 11/03/2009Speech/Language Evaluation, 11/03/2009

. • ' '•• ! ' . [ • • .? ':•

Other Options Considered Reasons for Rejection

Wintjna K Piscitelli page 3 of 8

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The Cornrmttee considered a general education setting This option was rejected because Winona's current languagewith support services such as related services and. processing needs indicate that a more intensive setting withconsultation services. support is needed to address the needs.The Committee considered a special class program. This option was rejected because it would be overly restrictive

and Winona's needs could be met in a less restrictiveenvironment.

Identify when periodic reports on the progress the student is making toward meeting the annual goals will be provided to thestudent's parents:

Manner: Written Report? Frequency: 4 limes during (he school year.

'GOALS.* For students with severe disabilities who would meet the eligibility criteria to take the New York State Alternate Assessment,the IEP must also include short term instructional objectives and benchmarks for each annual goal.Annual Goal: What the student will be expected to be able to do by the end of the year in which the IEP is hi effect.Evaluation Criteria: How well and over what period of time the student must demonstrate performance hi order to considerthe annual goal to have been met.Procedures to Evaluate Goal: The method that will be used to measure progress and determine if the student has met theannual goal.Evaluation Schedule: The dates or intervals of time by which evaluation procedures will be used to measure the student'sprogress.

SPEECH / LANGUAGEAnnual Goal

1. Winona will produce 6 target sounds in isolation, syllables, all position of words, and blends during the therapysession.

Evaluation Criteria: 80% success, over 4 weeksProcedure to Evaluate Goal; Recorded observationsEvaluation Schedule; By the next IEP Annual Review datePrimary Responsibility: Speech/Language Therapist


Criteria: 80% success, over 4 weeksSchedule/By: quarterly



Annual Goal2. Winona will eliminate the use of phonological processes (e.g., deletion of final consonants, initial voicing, syllable

reduction, and stopping).Evaluation Criteria: 80% success, over 4 weeksProcedure to Evaluate Goal: Recorded observationsEvaluation Schedule: By the next IEP Annual Review datePrimary Responsibility: Speech/Language Therapist

1. Winona will eliminate the use of phonological processes (c.g,, deletion of final consonants, initial voicing,syllable reduction, and stopping).

Criteria: 80% success, over 4 weeks

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01/28/2010 14:35 631-345-2165 • PAGE 06/09

Schedule/By: quarterly

2. Winona wf U eliminate the use of phonological processes (e.g., deletion of final consonants, initial voicing,syllable reduction, and stopping).


Annual Goal3. Winona will respond to a simple "Wh" question asked by a therapist, using at least 5 words per utterance,

Evaluation Criteria: 80% success, over 4 weeksProcedure to Evaluate Goal: Recorded observationsEvaluation Schedule: By the next IEP Annual Review datePrimary Responsibility: Speech/Language Therapist

1. Winona will respond to a simple "Wh" question asked by a therapist, using at least 3 words per utterance.Criteria: 80% success, over 4 weeksSchedule/By; quarterly

2. Winona will respond to a simple "Wh" question asked by a therapist, using at least 4 words per utterance.Criteria: 80% success, over 4 weeksSchedule/By: quarterly

Annual Goal4. Winona will identify and use basic and linguistic concepts (e.g., small/large, either, first/last) by pointing to or

labeling pictures.Evaluation Criteria: 80% success, over 4 weeksProcedure to Evaluate Goal: Recorded observations

. Evaluation Schedule: By the next IEP Annual Review datePrimary Responsibility: Speech/Language Therapist

1. Winona will identify and use basic and linguistic concepts (e.g., small/large, either, first/last) by pointing to orlabeling pictures.


2. Winona will identify and use basic and linguistic concepts (e.g., small/large, either, first/last) by pointing to orlabeling pictures.


Annual Goal5. Winona will follow 6 multi-step directions presented orally (e.g.. point to the big car before pointing to the red

bicycle) incorporating basic and linguistic language.Evaluation Criteria: 80% success, over 4 weeksProcedure to Evaluate Goal: Recorded observationsEvaluation Schedule: By the next IEP Annual Review datePrimary Responsibility: Speech/Langua£e Therapist

1. Winona will follow 2 multi-step directions presented orally (e.g.. point to the big car before pointing to the redbicycle) incorporating basic and linguistic language.

Criteria: 80% success, over 4 weeksScb.edu.le/By: quarterly

2.

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01/28/2010 14:35 631-345-2165 • PAGE 07/09

Winona will follow 4 multi-step directions presented orally (e.g., point to the big car before pointing to the redbicycle) incorporating basic and linguistic language.


Annual Gnal6. Winona will comprehend and use correct nouns (e.g., regular and irregular) and verb tense (e.g., present

progressive, regular past tense, irregular past tense).Evaluation Criteria: 80% success, over 4 weeksProcedure to Evaluate Goal: Recorded observationsEvaluation Schedule: By the next IEP Annual Review datePrimary Responsibility: Speech/Language Therapist

1. Winona will comprehend and use correct nouns (e.g.. regular and irregular) and verb tense (e.g., presentprogressive, regular past tense, irregular past tense).

Criteria; 60% success, over 4 weeksSchedule/By: quarterly

2. Winona will comprehend and use correct nouns (e.g., regular and irregular) and verb tense (e.g., presentprogressive, regular past tense, irregular past tense).


SOCIAL / EMOTIONAL / BEHAVIORALAnaaaLGoal

7. Winona will display the ability to play cooperatively, take turns, and sbare materials without inappropriatelydisplaying frustration.

Evaluation Criteria: 80% success, over 4 weeksProcedure to Evaluate Goal: Recorded observationsEvaluation Schedule; By JunePrimary Responsibility: Special Education Teacher

1. Winona will display the ability to play cooperatively, take turns, and share materials without inappropriatelydisplaying frustration.

Criteria: 60% success, over 4 weeksSchedule/By; quarterly

2. Winona will display the ability to play cooperatively, take turns, and share materials without inappropriatelydisplaying frustration.

Criteria: 70% success, over 4 weeksSchedule/By; quarterly

Annual Goal8. Winona will correctly follow the classroom morning routine (e.g., unpack own backpack, put away personal

belongings and school materials, join in circle time, independently work on seat-time activity).Evaluation Criteria: 80% success, over 10 weeksProcedure to Evaluate Goal: Recorded observationsEvaluation Schedule: By the middle of JunePrimary Responsibility: Special Education Teacher

1. Winona will correctly follow the classroom morning routine (e.g., unpack own backpack, put away personalbelongings and school materials, join in circle time, independently work on seat-time activity).

Criteria: 80% success, over 10 weeksSchedule/By: By the middle of June

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01/28/2010 14:35 631-345-2155 PAGE 08/09

Annual Goal9. Winona will transition appropriately (e.g,, willingly prepare for next activity, refrain from tantrums, appropriately

express disappointment when experienced) from classroom to special subject areas.Evaluation Criteria; 80% success, over 4 weeksProcedure to Evaluate Goal: Recorded observationsEvaluation. Schedule: By JunePrimary Responsibility: Special Education Teacher

1. Winona will transition appropriately (e.g., willingly prepare for next activity, refrain from tantrums,appropriately express disappointment when experienced) from classroom to special subject areas.


2. Winona will transition appropriately (e.g., willingly prepare for next activity, refrain from tantrums,appropriately express disappointment when experienced) from classroom to special subject areas.

Criteria; 70% success, over 4 weeksSchedule/By: quarterly

Annual Goal10. Winona will remain on task during the class lessons (e.g. student will appear to focus attention on presented

materials, will refrain from engaging in distracting social interactions).Evaluation Criteria: 80% success, over 4 weeksProcedure to Evaluate Goal: Recorded observationsEvaluation Schedule: By JunePranary Responsibility: Special Education Teacher

1. Winona will remain on task during the class lessons (e.g. student will appear to focus attention on presentedmaterials, will refrain from engaging in distracting social interactions).


r2. Winona will remain on task during the class lessons (e.g. student will appear to focus attention on presented

materials, will refrain from engaging in distracting social interactions).Criteria: 70% success, over 4 weeksSchedule/By: quarterly

BASIC COGNITIVE / DAILY LIVING SKILLSAnnual Goal

11. Winona will identify at least 10 printed letters of the alphabet.Evaluation Criteria: 70% success, over 4 weeksProcedure to Evaluate Goal: Classroom testsEvaluation Schedule: By JunePrimary Responsibility: Special Education Teacher

1. Winona will identify at least 10 printed letters of the alphabet.Criteria: 50% success, over 4 weeksSchedule/By: quarterly

2. Winona will identify at least 10 printed letters of the alphabet.Criteria: 60% success, over 4 weeksSchedule/By: quarterly

Annual Goal

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12. When presented with different colors on cards, Winona will identify 10 bask colors.Evaluation Criteria: 80% success, over 4 weeksProcedure to Evaluate Goal: Classroom testsEvaluation Schedule: By JunePrimary Responsibility: Special Education Teacher

1. When presented with different colors on cards, Winona will identify 4 basic colors.Criteria; 80% success, over 4 weeksSchedule/By: quarterly

2. When presented with different colors on cards, Winona will identify 8 basic colors.Criteria: 80% success, over 4 weeksSchedule/By; quarterly

Annual Goal13. Winona will sort, group and classify 4 objects.

Evaluation Criteria: 80% success, over 4 weeksProcedure to Evaluate Goal: Classroom testsEvaluation Schedule: By JunePrimary Responsibility: Special Education Teacher

1, Winona will sort, group and classify 2 objects.Criteria: 80% success, over 4 weeksSchedule/By: quarterly

2. Winona will sort, group and classify 4 objects.Criteria: 80% success, over 4 weeksSchedule/By: quarterly

Annual Goal14. Winona will reproduce three-dimensional block designs from a model.

Evaluation Criteria: 80% success, over 4 weeksProcedure to Evaluate Goal: Classroom testsEvaluation Schedule: By JunePrimaiy Responsibility: Special Education Teacher

1. Winona will reproduce three-dimensional block designs from a model.Criteria: 60% success, over 4 weeksScheduJe/By: quarterly

2. Winona will reproduce three-dimensional block designs from a model.Criteria: 70% success, over 4 weeksSchedule/By: quarterly

Winona R Piscittslli page £ ofS

Sieve HeldExecutive Director

Stephen GordonDirector

C*thy CunfannoDirector of Children's Services

Middle IslandLong wood RoadP.O. Box 12Middle Island, NY11953(631)924-0008 Phone(631) 924-1243 Fax

Lindcnhurst887 Kellum StreetLindenhurst, NY11757(631) 884-3000 Phone(631) 884-1959 Fax

Riverhead556 East Main StreetRiverhead, NY 11901(631)369-1927 Phone(631)369-1957 Fax

William Floyd99 Lexington RoadShirley, NY 11967(631) 281-6800 Phone(631) 281-6096 Fax

JUST KIDS| Early Childhood Learning Center

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Structured Observation

yName: Winona PiscitelliI D.O.B.: 7/06/05Observer: Patricia Walter, M.S.

Date: 11/17/09Time: 9:05-9:45 am

Winona currently attends pHBBi Preschool five days a week. There were 15children and 2 adults present during this observation.

Winona was playing with two peers in the housekeeping area when the observerarrived. She was noted to verbalize during imaginative play and use toys in a functionalmanner. When one of her peers asked her to get a plate (since they were cutting up apizza pie) Winona retrieved a spoon and brought it back to the table. Her peer said, "No, aplate!" and Winona then picked up a measuring cup to show. The other child picked up aplate, showed Winona and said, "This is a plate!" Winona smiled and nodded.

Several minutes later, Winona noticed the observer. She ran up and hugged theunfamiliar person. Winona stated her name when asked and briefly showed interest in theconversations of other children and the observer. She then scribbled briefly on the chalkboard and returned to the observer to show a piece of broken chalk. Next, Winona skippedaround the classroom and briefly stopped to watch a child complete an art activity with anadult. The adult asked Winona if she had already had a turn to make a turkey and Winonanodded her head in agreement.

When Ms. Nicki, Winona's teacher, announced that it was time to clean up the toysWinona continued to skip around the room until her individual name was called. Herteacher asked her to help put away the toys in the housekeeping area. Winona walked tothe housekeeping area and hid behind the refrigerator. She did not follow the teacher'sverbal directives but eventually responded when visual cues were present. (Her teacherhanded her a basket with a photograph of food items that belonged in the container.)Winona placed several items appropriately in the basket and then began to skip and hoparound the room. She laughed and nodded her head "no" when continuously told to put thetoys away.

Her teacher explained to Winona that she would have to 'sit out' if she didn't helpclean up. After running and laughing, Winona was walked to a chair with physical[prompting. Her teacher sat with her and explained that she needed to help her class.

'hen Winona stated she was ready to help, the teacher told her to put a specific toy away.Winona followed through and placed it where it belonged. Winona then joined the childrenon the carpeted area. She held hands with her peer as they sang a "Hello" song and satdown when told. As Winona listened to a short story she was noted to chew on her rightthumb. She attempted to sing along with the songs and participate in non-verbal tasksalthough she did not appear to know the words to the familiar preschool songs. Winona•ecognized her name in print, with prompting. She attempted to spell her name as theeacher pointed to the letters; however, she named various letters randomly. When some

of the children left the room to use the bathroom, Winona and several peers remained to

Winona Piscitelli Structured Observation Page 2

play Simon Says. She seemed to have difficulty identifying many of her body parts and reliedon the visual cues of others to follow through.

According to Ms. Nicki, Winona's teacher, the behaviors observed were typical. Winonareportedly enjoys participating in classroom activities. Winona will attempt to sing songs andengage in motor tasks with her peers. She has a difficult time following directions anddemonstrates poor conceptual knowledge of basic skills.

Patricia Walter, M.S.Special Education Teacher

11/13/2089 14:15 631-345-2165PAGE 02/02

i Central School DistrictCommittee on Preschool Special Education

Office of Special Education

Agency Invitation for Committee on Preschool Special Education Meeting

Dear:

November 10,2009

Re; Winona PisatelH

The parent or guardian of the above named child has been invited as a member to attend the meeting of theCommittee oir Preschool Special Education. The Committee is inviting an appropriate representative fromyour agency to attend. Please note the date, time and place of the meeting so that the necessary arrangementsmay be made to attend.

The meeting is scheduled for:

Date: 11/20/2009

Time: 09:00 AM

Place: Special Education Office

Purpose: Initial Eligibility Determination Meeting

If you have any questions, please do not hesitate to call. So that we may plan accordingly, please contact ouroffice to confirm the attendance of a representative from YDUT agency. Thank you for your cooperation inthis regard. ' ^ **

Sincerely,

JuliMulcahy

MtMulcahyCoordinator of Pre-K & Elementary Special Ed,

Cam-Held Enterprises, Inc..aa^tj^m^i^^tt^ffffl^gjg^g^f^t^^^^g

Maiimg Address: P.O. Box 12 e Middle Island © New Yoik 1 1953

Dear CPSE Chairperson:

Enclosed is the evaluation packet for

The evaluation packet includes the fol lowing:

Date

6 Preschool Summary

f Social History :

0 Structured Observation

9 Psychological Evaluation ///1 /£)*? .' x

f Speech/language Evaluation ///<3/0/r - r j y >,/ / '/ * ^ '-*" £

% Occupational Therapy Evaluation

0 Physical Therapy Evaluation """•-'<* O o;• j *****

9 Audiological

0" Educational Evaluation

0 Vision Evaluation

0 Birth Certificate

0 Physical Examination*

9 Immunization record

0 Child/Preschool Outcome Summary Form

If you have any questions, I can be reached at 924-0008, ext.208. The CPSE meeting is important. I hope you can attend.

'"'

Robin Richman, MS.Ed.Evaluation Coordinator

enc.sen

Cam-Held Enterprises, Inc.Longwood Road © Middle Island o. New York o (631) 924-0008

Mailing Address: P.O. Box 12 o Middle Island ® New York 11953

Dear P a r e n t ( s ) / G u a r d i a n ( s )

Enclosed is the evaluation packet for

Your evaluation packet includes the following:

6 Preschool Summary - (a summary of each evaluation)@ Social History .$ Psychological Evaluationf Speech/language Evaluationf> Occupational Therapy Evaluation . . . - . .0 Physical Therapy Evaluation . . . . - . . - ~ -8 Audiological .0 Educational Evaluation0 Vision Evaluation9 Birth CertificateS> Physical Examination*§) Immunization record9 Child/Preschool Outcome Summary Form (to be discussed at CPSE)

*Please note that if this is an initial evaluation, and thephysical examination is not included in the packet, or the schooldistrict has not been provided a copy, the Committee on PreschoolSpecial Education (CPSE) meeting may be cancelled.

Please review these evaluations and contact me if there are anyquestions about the reports so that they can be discussed priorto the CPSE meeting. Your school district will contact youregarding the date of the CPSE meeting.

The recommendations on the reports are' only recommendations, andfinal eligibility and determination of frequency and location ofservices will be made at the CPSE meeting.

Possibilities of location may include-.

- in your home- at a therapeutic center (i.e., Just Kids, NIS, Alternatives)- at preschool or day care- in a baby sitter's home

I can be reached at 924-1000, ext. 208. The CPSE meeting isimportant. I hope you can attend.

Robin. Richman, MS . Ed .Evaluation Coordinator

enc.let

Steve HddExecutive Director


Cathy CianfaruioDirector of Children's Services

Middle IslandLongwood RoadP.O. Box 12Middle Island, NY11953(631)924-0008 Phone(631)924-1243 Fax

Lindenhurst887 Kellum StreetLindenhurst, NY11757(631) 884-3000 Phone(631) 884-1959 Fax


William Floyd99 Lexington RoadShirley, NY 11967(631) 281-6800 Phone

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Preschool Student Evaluation Summary Report

STUDENT: Winona Piscitelli

DATE OF BIRTH: 7/6/2005

FOSTER PARENT(S)J

LEGAL GUARDIAN: Lori Towns

RELATIONSHIP: DSS Caseworker

ADDRESS: P.O. Box 18100, Hauppauge

COUNTY OF RESIDENCE: Suffolk

EVALUATION DATES: 11/3/09- 11/6/09

AGENCY: Just Kids Learning Center

CONTACT PERSON: Robin Richman

PHONE: 924-0008

SCHOOL DISTRICT4

CURRENT LEVEL OF SERVICES: None; attends preschool

This report is a summary of the findings of the evaluation which includes a detailed statement of the child's individualstrengths and needs. It indicates the individually administered evaluation measures used, including the result of the observationof the child and the findings pertinent to the suspected disability. This summary and the documentation of the evaluation resultsare transmitted to all members of the Committee on Preschool Education and to the Municipality Representative. Thesummary is also transmitted to the parent

Cognitive Development:

Winona's Full Scale IQ of 69 (2nd percentile) on the WPPSI-III indicates her performance to fallwithin the Extremely Low range of intelligence and well below normal limits (>-2 Standard Deviations).This Full Scale IQ is comprised of a Borderline range Performance IQ of 73 (4th %ile, -1.7 SD) and anExtremely Low range Verbal IQ of 67 (1 st%ile, >-2 SD). Winona performed within the Low Average toAverage range on 2 of the 9 subtests administered; relative strengths were noted in her ability tocomplete visual patterns (37th %ile) and in her visual processing speed (16th %ile). Scores on theremaining subtests fell at or below the 5th %ile. Although self-directed, Winona responded well toredirection. She appeared motivated, however, she struggled to maintain her focus andconcentration. She often repeated the test items back and did not appear to understand what wasbeing asked of her. She required additional teaching trials for most tasks.

Social/Emotional Development:

Winona was removed from her biological mother's care due to neglect and placed in fostercare in 9/09; she sees her biological mother weekly. On the Socialization domain of the Vineland-ll,Winona's S.S. of 79 (8th %ile, -1.4 SD) fell within the Below Average range. Winona demonstratesfriendship-seeking behavior with others the same age; sometimes responds appropriately whenfamiliar adults make small talk; uses actions, but not yet words to express happiness or concern forothers; has difficulty with social boundaries; sometimes plays cooperatively with more than one child;has difficulty with snaring and turn taking; says thank you when given something; sometimes respondsappropriately to reasonable changes in routine; sometimes acts appropriately when introduced tostrangers; and sometimes says she is sorry after hurting another's feelings. Her foster mother'sresponses to the Achenbach CBCL revealed that Winona does not present with any significantbehavioral concerns, however, she did not concerns regarding Winona's temper tantrum behavior and"meltdowns" (e.g., cries, yells, thrashes). It was also reported that Winona has difficulty transitioningand at times appears to be over-stimulated by the environment. Winona is described as impulsiveand hyperactive. She runs and jumps around the house and is rough with others. Her teacher'sresponses to the Achenbach CTRF yielded a Borderline elevation on the Aggressive Behavior scaleand a Clinically Significant elevation on the Attention Problems scale. In the school environment,Winona has great difficulty concentrating; cannot seem to sit still; sometimes has difficulty following

Winona Piscitelli Preschool Student Evaluation Summary Report Page 2

directions and carrying out assigned tasks; is often inattentive; sometimes hits or gets into fights withothers; is often defiant; and does not seem to feel guilty after misbehaving.

Physical Development:

Little information is known about Winona's birth and medical history prior to September of 2009.She was treated for burns to her right wrist in 4/09. Since being enrolled in preschool, she hasexperienced several common colds/illnesses. A recent audiological evaluation revealed normal hearingsensitivity in both ears with normal middle ear function bilaterally. Winona's S.S. of 81 (10th %ile, -1.3 SD)on the Vineland-ll Motor Skills domain indicates her overall motor skills to be in the Below Average range.Winona sometimes walks up and down stairs alternating feet; runs smoothly changing direction and speed;rides a bicycle with training wheels; sometimes catches a beach ball-sized ball from at least 6 feet away;holds a pencil or crayon in the proper position; can draw at least one recognizable form but does not yetmake recognizable letters or numbers; has difficulty opening and closing scissors with one hand;sometimes colors simple shapes; and draws a circle freehand while looking at an example. As per thePDMS-2, Winona's fine motor/perceptual skills are within the upper limits of the Below Average range (FMQof 88, 21st%ile). With the exception of a mild weakness in her grasping skills, Winona exhibits adequatevisual motor integration skills. Her cutting with scissors is choppy. Her graphomotor design copy skillsare weak (TVMS-R, S.S. 68, 2nd %ile, >-2 SD), however, this may be due to lack of exposure. On theSensory Profile, Winona's foster mother's responses revealed that Winona presents with some concerns inthe areas of touch processing, emotional/social responses, and behavioral outcomes of sensoryprocessing.

Language and Communication Development:

Results of the PLS-4 indicate that both Winona's ability to understand language (Auditory Comp-rehension, S.S. 65,1st %ile, >-2 SD) and her ability to use language to communicate (Expressive Communi-cation, S.S. 64, 1st %ile, >-2 SD) are significantly delayed. Receptively, Winona followed two-stepdirections but had difficulty understanding most age-expected language concepts. Expressively, sheanswered simple questions, used a variety of nouns, modifiers, and pronouns, and produced basic 4-5word utterances, but did not answer questions logically or about hypothetical events or complete analogies.Winona's sentence length (MLU) could not be accurately assessed as her speech was significantlycompromised by speech sound production errors, particularly in connected utterances. Pragmaticlanguage skills were at the 3-4 year range. As per the GFTA-2 (S.S. 60, 3rd %ile, >-2 SD) and the KLPA-2(S.S. 49,1st %ile, >-2 SD), both Winona's articulation skills and phonological development, respectively, arewell below normal limits. Overall intelligibility is judged to be poor. Winona was 75% intelligible inconnected speech when contextual cues were available, and <50% intelligible in unfamiliar situations.Upon informal observation, all oral peripheral structures were symmetrical and had adequate range ofmotion for speech and vegetative purposes. During the evaluation, Winona presented with a slightlyhyponasal quality to her voice that appeared to be the result of nasal congestion.

Adaptive Behavior:

Self-help skills, as assessed via parent report on the Vineland-ll, fell within the Below Averagerange (Daily Living Skills, S.S. 77, 6th %ile, -1.5 SD). Winona sometimes performs the following: uses thetoilet without help; puts on clothing that opens in the front (does not yet fasten snaps or zip zippers),brushes her teeth without help; clears unbreakable items from her place at the table; puts away personalpossessions; is careful when around hot objects; uses the TV or radio without help; demonstratesappropriate behavior while riding in a car; and follows household rules.

Date summary and evaluations sent to the parent, Committee on Preschool Special Education including theMunicipality Representative and Suffolk County: ? Jj

Steve HeldExecutive Director

Stephen CordonDirector

Cathy CianfaranoDirector of Children's Service!



Riverhead556 East Main StreetRiverhead, NY 11901(631) 369-1927 Phone(631)369-1957 Fax

William Floyd99 Lexington RoadShirley, NY 11967(631) 281-6800 Phone

u

WJ JUST KIDSI Early Childhood Learning CenterwQ Social History Summary

^Name: Winona Piscitelli5D.O.B.: 7/6/05i

Reason for Referral:

Date: 11/3/09Denise Ahlgrim, LMSW

Winona (Nona) is a 4 year 5 month old white female child who is being referred forthis CPSE evaluation at the request of SCDSS foster care worker, Lori Towns, andWinona's foster mother, Lisa Carbone on the consent of the ItfMpMHbSchool District.Information in this report was obtained during a center based interview with Ms. HfeHftatJust Kids and a phone interview with Ms. Towns. The child's language is English.

Ms^HMHfctconcerns f°r Winona are in the areas of speech and languagedevelopment, and behavior. Winona's speech is described as difficult to understand andMs.<^dHB&'s noj sure gj yy|nona a|ways comprehends what she is told. Times oftransition are also said to be difficult for Winona. She will often scream, cry, thrash, andlook "overwhelmed." CPS had referred Winona's biological mother to obtain evaluations forher daughter previously, however, evaluations were never obtained. Upon moving to hercurrent foster home, Winona began attending preschool at St. David's in Riverhead. Sheattends Monday - Friday 8:30-4:30. Winona's medical needs are followed by Dr. Festa.

Family History:

Winona currently resides with foster mother

anni Girl. Winona sees Ms.is relationship is said to be positive for

/mona.

Winona was placed in the custody of SCDSS on September 16, 2009 and with Ms.on September 23, 2009 after a brief stay at a different foster home. CPS has

been providing services for Winona's mother at different times over the past 2 years.Winona and her mother moved from their Nassau County, NY home in 2007. At that time,Winona's father was unable to find them. Winona and her mother have since resided inseveral counties in New York, as well as in Ohio. Currently, Winona has supervised visitsonce weekly with her mother. Winona's father is establishing paternity and working toobtain custody of Winona.

Winona has one adult brother (21), who is diagnosed with autism and who lives in aresidential facility in Northern NYS. Winona's mother's parental rights for him wereterminated in 2004. Winona has no contact with her brother. Extended family medicalhistory is reported to include mental retardation, autism, and mental health problems.

Winona

Winona Piscitelli Social History Summary Page 2

Medical History:

Limited information regarding Winona's prenatal, birth, and postnatal histories isavailable. Winona was born at Nassau County Medical Center. Prior to living in her currentfoster home, Winona last received routine medical care in 2006. In April 2009, Winona wastaken to the emergency room in Richland City, Ohio, due to burns on her right wrist after beinginjured in a fire pit. She currently has a scar on her wrist. Ms.'•••Rioted Winona has hadmultiple illnesses since beginning her first preschool experience, but is otherwise described ashealthy. Ms.,aAH|MB»is currently looking into bringing Winona to her first dental check-up.

Developmental History:

No developmental history was able to be obtained from Winona's mother whenrequested by foster care worker, Lori Towns.

Winona uses a variety of cups, a fork, and a spoon when feeding herself. She eats welland enjoys a variety of foods including hamburgers, fruit, peas, and corn. A recent physicalevaluation revealed that Winona is above the 95th percentile for her weight. MMHHBfe notedthat she has introduced Winona to a more healthy diet and that Winona has since lost sevenpounds.

Winona is toilet trained and has recently stopped using pull-up diapers at night. Ms.>did not report any concerns with Winona's ability to dress/undress herself. Ms.• stated that Winona currently sleeps in her own room in a twin bed. She takes naps on

the weekend. When initially placed in Ms. iWHNB^home, Winona cried periodically duringthe night; this has significantly decreased. Winona exhibits some difficulty with washing, whichmay be related to her burn incident. She bites her finger and toe nails and plays with her saliva.

Ms. MBB^Ktescribes Winona as a silly, sweet, funny, child who is sociable and enjoyshugs and affection when she initiates it. Winona loves outside play, Dora, Diego, and SpongeBob characters. Winona's activity level is described as high and her attention span whenplaying alone is said to be short and fleeting. Winona runs often inside and outside. Ms.

£BBHHtodescribed Winona's "meltdowns" as screaming, thrashing, and crying when transitionsoccur. They are noted to be worse if Winona is sick or tired:J/\^king up and starting the day issaid to be difficult. Although these behaviors still exist, Ms!*ttlVHHMnas seen ongoing progressand a decrease in behaviors since Winona arrived at her home. Winona is described to loveother kids and will talk about her friends from school. She is said to have adjusted well toschool and her teachers tell Ms. HMUfcthat Winona seems to be enjoying herself at school.

Impressions:

Ms. •••rimpresses as a kind, caring, foster parent who is actively involved in allareas of Winona's wellness at this time. It is her hope that Winona can benefit from any serviceshe is found eligible to receive. The CPSE process was discussed with Ms. Carbone and shewas encouraged to call this worker with any future/questions.

Denise AnlgriSocial Worker

DA/vIc

Stcvt HeldExecutive Director

Stq>hen GordonDirector

Cathy CuniaranoDirector of Children's Services



Rlverhead556 East Main StreetRiverhead, NY 11901(631) 369-1927 Phone(631) 369-1957 Fax



Psychological Evaluation

Date: 11/3/2009C.A.: 4:3

Name: Winona PiscitelliD.O.B.: 07/06/2005Evaluatof: Diana DeStefano-DiLuca, M.A.

Reason for Referral:

Winona was referred for a psychological evaluation to determine eligibility forspecial education services. Concerns were noted regarding her articulation skills andpossible sensory related problems.

Relevant Background Information:

Winona was removed frorrHTerrnother's care on September 16th due to neglect andnow lives with her foster mother BBHBfce. Winona sees her biological mother weeklyfor supervised visits. Her father is trying to get custody of Winona at this time, but is waitingon the results of a paternity test.

Winona attends preschool at St. David's School in Riverhead. This is her firstschool experience. A conversation with her teacher reveals that Winona is a "good kid"who is trying very hard. She presents with some difficulty in her attentional skills andrequires a fair amount of adult redirection in order to carryout assigned tasks. Winona getsalong fairly well with her peers but has difficulty communicating her needs due toexpressive language difficulties.

A detailed social history report has been generated by the social worker and can befound on file.

Behavioral Observations:

Winona presented as a socially engaging and outgoing four year and three monthold girl. She was immediately friendly. Winona unreservedly showed the evaluator herDora bag and sippy cup. She took a general interest in the tasks presented to her, butneeded a fair amount of prompting and direction to get started. Winona was somewhatself-directed but willingly accepted help and redirection. She appeared motivated to dowell, but struggled to sustain her focus and concentration for the duration of theadministration. Winona possessed a sweet nature. She smiled and worked cooperativelywith the evaluator. Winona evidenced difficulty with articulation and word structure. Shewas unable to explain ideas in complete sentences and used gestures whenever possibleto answer questions. Winona often repeated the questions back to the evaluator and oftenseemed not to understand what was being asked of her. Questions were repeated anddirections were re-explained, as Winona needed additional teaching trials for most tasks.Winona's also evidenced weaknesses in her motor skills. She sometimes used a palmergrasp for increased support when holding her pencil. Winona had difficulty copying simpledesigns as well as with printing in the correct orientation (left to right). At the end of theevaluation, Winona waved to the evaluator and said, "Bye teacher."

Psychological Evaluation Page 2Winona Piscitelli

Assessment Procedures:

Parent Interview

Wechsler Preschool and Primary Scale of Intelligence - Third Edition (WPPSI-III) Mean =100, SD = 15

CompositeVerbal IQPerformance IQFull Scale IQGlobal Language Composite

SubtestsPerformance

Block DesignMatrix ReasoningPicture ConceptsCoding

VerbalInformationVocabularyWord Reasoning

Global LanguageReceptive VocabularyPicture Naming

Standard Score67736970

1st

4th

ond

2nd

RangeExtremely LowBorderlineExtremely LowBorderline

Scaled Score %ile

5937

444

54

5th

37th

1st

16th

ond

ond

5th

2nd

Average Range of Scaled Score = 8 to 12

Vineland II Adaptive Behavior Scales (Mean 100, SD=15)Domain Standard ScoreCommunication 65Daily Living Skills 77Socialization 79Motor Skills 81Adaptive Behavior Composite 72

Achenbach Child-Behavior Checklist (CBCL)Syndrome Scales T-ScoreEmotionally Reactive 55Anxious/Depressed 50Somatic Complaints 50Withdrawn 51Sleep Problems 59Attention Problems 53Aggressive Behavior 58

Internalizing 43Externalizing 57Total Problems 54

*WNL= Within Normal Limits

1st

6th

8th

10th

«rd

Percentile69th

<50th

<50m

54th

81st

62nd

79th

24th

76th

65th

RangeLowBelow AverageBelow AverageBelow AverageBelow Average

RangeWNLWNLWNLWNLWNLWNLWNL

WNLWNLWNL

Winona Piscitelli Psychological Evaluation

Achenbach Teacher-Caregiver Form (CTRF)

PageS

Syndrome ScalesEmotionally ReactiveAnxious/DepressedSomatic ComplaintsWithdrawnAttention ProblemsAggressive Behavior

InternalizingExternalizingTotal Problems

Assessment Results and Interpretation:

T-Score525650567566

546867

Percentile58th

73rd

<50th

73rd

>97th

95th

65th

97th

96th

RangeWNLWNLWNLWNLClinicalBorderline

WNLClinicalClinical

On this administration of the WPPSI-III, Winona obtained a Full Scale IQ of 69. Thisscore falls within the Extremely Low range and is representative of the 2nd percentile withrespect to same-aged peers. The Full Scale IQ is derived from a Verbal IQ of 67 (1st

percentile), which falls within the Extremely Low range, and a Performance IQ of 73 (4th

percentile), which falls within the Borderline range. A General Language Composite wasobtained to further assist in evaluating Winona's language skills. A score of 70, 2nd percentilewas obtained. This score falls within the Borderline range.

Subtest analysis of the Verbal domain reveals borderline range skills. Winonademonstrated delays in her ability to answer questions regarding general knowledge whenpresented with visual cues. She had difficulty labeling minor body parts and answeringquestions verbally. Winona identified 3 out of 12 pictures of common objects. She was unableto explain the function of objects. Winona also had difficulty identifying pictures of commonconcepts as well as with identifying concepts when the information was presented verbally.

Subtest analysis of the Performance domain reveals scattered skills spanning from theextremely low to average range. Winona demonstrated extremely low range skills in her abilityto understand increasingly abstract relationships between common objects. She demonstratedborderline range skills in her ability to perceive and manipulate visual patterns rapidly, such asin completing block designs. Winona demonstrated low average range skills in her ability tocopy simple designs accurately and quickly. She demonstrated average range skills in herability to identify and complete patterns. This is considered an area of personal strength.

Winona's foster mother completed the Vineland II survey form. Based on her report ofWinona's abilities in the Communication, Daily Living Skills, Socialization, and Motor Skillsdomains, her adaptive behavior scores fall within the low to below average range.

Survey results from the Communication domain indicate Low range skills. Winonasometimes sits and attends to a story for 5 minutes; points to at least five minor body partswhen asked; sometimes follows two-part instructions; sometimes tells about experiences insimple sentences; usually does not say her correct age when asked; identifies 2-5 commoncolors; and says less than 100 recognizable words. Winona does not yet use possessives orpronouns, nor does she use present tense verbs ending in "ing."

Winona Piscitelli Psychological Evaluation Page 4

Survey results from the Daily Living Skills domain indicate Below Average range skills.Winona sometimes uses the toilet without help; puts on clothing that opens in the front; shedoes not yet fasten snaps or zip zippers; she sometimes brushes her teeth without help;sometimes clears unbreakable items from her place at the table; sometimes puts away personalpossessions; is careful when around hot objects; sometimes uses the TV or radio without help;sometimes demonstrates appropriate behavior while riding in a car; and sometimes followshousehold rules.

Survey results from the Socialization domain indicate Below Average range skills.Winona demonstrates friendship-seeking behavior with others the same age; sometimesresponds appropriately when familiar adults make small talk; uses actions, but not yet words toexpress happiness or concern for others; has difficulty with social boundaries; sometimes playscooperatively with more than one child; has difficulty with sharing and turn taking; says thankyou when given something; sometimes responds appropriately to reasonable changes inroutine; sometimes acts appropriately when introduced to strangers; and sometimes says she issorry after hurting another's feelings.

Survey results of the Motor Skills domain indicate Below Average range skills. Winonasometimes walks up and down stairs alternating feet; runs smoothly changing direction andspeed; rides a bicycle with training wheels; sometimes catches a beach ball-sized ball from atleast 6 feet away; holds a pencil or crayon in the proper position; can draw at least onerecognizable form but does not yet make recognizable letters or numbers; has difficulty openingand closing scissors with one hand; sometimes colors simple shapes; and draws a circlefreehand while looking at an example.

Winona's foster mother completed the Achenbach Child Behavior Checklist (CBCL).Based on her response set, all scales fall within normal limits. However, during the interviewwith Winona's foster mother, concerns were noted regarding temper tantrum behavior and"meltdowns" (e.g., cries, yells, thrashes). It was also reported that Winona has difficultytransitioning and at times appears to be overstimulated by the environment. Winona isimpulsive and hyperactive. She runs and jumps around the house and is rough with others.Winona resists taking naps.

Winona's teacher completed the Achenbach Caregiver-Teacher Report Form (CTRF).Based on her report of Winona's classroom behavior, the following scales yielded elevatedscores:

Borderline range- Aggressive BehaviorClinically Significant- Attention Problems

These findings reveal that at school Winona has great difficulty concentrating; cannotseem to sit still; sometimes has difficulty following directions and carrying out assigned tasks; isoften inattentive; sometimes hits or gets into fights with others; is often defiant; and does notseem to feel guilty after misbehaving.

Summary and Impressions:

Winona is a four year and three month old girl who attends preschool al4MMHBfcSchool in CMMfe!. She was referred for testing due to concerns regarding her articulationskills and possible sensory related problems. Based on the current evaluation, Winona'sintellectual skills are measured to fall in the Extremely Low range. Her overall IQ is assessed tobe 69, representative of the 2nd percentile. This score is comprised of a Verbal IQ of 67 (1st

Winona Piscitelli Psychological Evaluation Page 5

percentile), which falls within the Extremely Low range, and a Performance IQ of 73 (4th

percentile), which falls within the Borderline range. Winona demonstrated widely scattered skillsbetween the extremely low and average range of intelligence. A personal strength was noted inher ability to identify patterns.

According to the responses from the Vineland II, completed by Winona's foster mother,she demonstrates low range communication skills, and below average self-help, socialization,and motor skills. Based on the responses to items on the Achenbach Child Behavior Checklist(CBCL) all scores fall within normal limits, however, these results are not commensurate withthe concerns noted during the interview. Responses to items on the Caregiver-Teacher reportform resulted in a Borderline score on the Aggressive Behavior scale and a Clinically Significantscore on the Attention Problems scale.

According to this evaluation, Winona is exhibiting delays in her nonverbal and verbalreasoning skills as well as in her general concept development. Winona continues to havedifficulty identifying colors and does not yet recognize letters of the alphabet. During thisevaluation, she had difficulty answering questions verbally and responded in very simple andshort phrases. Winona presents with attentional difficulties and tendencies toward aggressivebehavior. In the classroom, Winona requires a fair amount of adult redirection in order to followinstructions and carryout assigned tasks. These behaviors were also observed during this one-to-one evaluation.

At this time, it is recommended that Winona receive the additional support of specialeducation services in a firm and structured educational setting in order to develop her cognitive,academic, and social-emotional skills. Final determinations for programs and services are to beestablished by the CPSE.

Diana DeStefano^DiLuca, M.A.School Psychologist

Middle IslandLongwood RoadP.O.Box 12Middle Island. NY11953(631)924-0008 Phone(631)924-1243 Fax

Lindcnhurst887 Kellum StreetLindenhurst, NYU757(631) 884-3000 Phone(631) 884-1959 Fax


William Floyd99 Lexington RoadShirley, NY 11967(631 (281-6800 Phone(631) 281-6096 Fax


Preschool Speech Language Evaluation

Steve HddExecutive Director

Stephen CordonDirector

Cathy CunhranoDirector of Children's Services

2-Name: Winona Piscitelli$DOB: 7/6/05

C.A.: 4 years, 4 monthsSchool District:

DOE: 11/3/09Evaluator: Lisa Valenti, MACCC/SLP

BACKGROUND AND REFERRAL INFORMATION:

Winona was referred to Just Kids for a speech and language evaluation in order to assessher need for CPSE services. Ms. £HMB> Winona's foster mother, expressed concernregarding Winona's speech and language development; particularly her limited intelligibilityand language comprehension. Ms.<ttMHB»has limited information regarding Winona'smedical and developmental history. Since Winona's placement, she has had a few colds;otherwise she appears to be healthy.

**Please refer to Social History section of this report for more comprehensive informationregarding developmental milestones and medical background.

BEHAVIORAL OBSERVATIONS:

Winona was immediately friendly and outgoing as testing commenced. She was reluctantto participate in formal testing; instead she gestured toward the toy cabinet and asked to"play". The evaluator attempted to redirect her to her chair, however she called for herfoster mother and stood by the table next to Ms. Carbone instead. She completed a fewlanguage test items and became distracted (e.g. laid across the table, independently turnedpages of the test manual, labeled the pictures). The evaluator presented articulation testsslates and Winona's attention improved. She named the items and smiled proudly inresponse to verbal praise. She easily transitioned back to language testing and was able tocomplete her assessment successfully. During informal play, Winona used toysappropriately and allowed the evaluator to participate in her activities. She was somewhatcongested during testing and often had to take "breaks" to wipe her nose and drink herwater. Despite her obvious discomfort, Winona was engaging and cooperative. No tempertantrum behavior was noted.

[EVALUATION BATTERY:

I. Preschool Language Scale-4 (PLS-4). A norm referenced test that assesses auditory:omprehension and expressive communication in children ages' birth to 6 years.

Auditory Comprehension:Expressive Communication:Total Language:

StandardScore65*64*61*

PercentileRank1st

1st

1st

StandardDeviation>-2.0 sd>-2.0 sd>-2.0 sd

Winona Piscitelli Speech/Language Evaluation Page 2

2. The Goldman-Fristoe Test of Articulation - a norm referenced test that provides asystematic means of assessing articulation problems in individuals between the ages of 2-0 and21 years.

Standard Score 60*Percentile 3rd

3. Khan Lewis Phonological Analysis- for use with the Goldman Fristoe Test of Articulation-the KLPA-2 is a norm-referenced test that provides a systematic means of assessingphonological processing in individuals between the ages of 2-0 and 21 years.

Standard Score 49*Percentile <lst

*Standard Score is based on a mean of 100 +/-15

4. Hearing Status5. Language Sample6. Oral Peripheral Examination7. Clinical Observation

INTERPRETATION OF TEST SCORES:

PLS-4:

Receptive Language Skills:The auditory comprehension section of the PLS-4 is used to evaluate how much language achild understands. The tasks designed for preschool-age children assess comprehension ofbasic vocabulary, concepts and grammatical markers. Formal language testing revealed asignificant delay in Winona's receptive language skills with a standard score of 65 and acorresponding percentile rank of 1. She pointed to pictures that depicted object function (e.g.what you ride), part/whole relationships (e.g. door of the car), negatives in sentences (e.g. notcrying) and simple descriptive concepts (e.g. big, little). She followed two-step related directionspresented with verbal cues only (e.g. get the cup and give it to me). She identified colorsaccurately. Winona did not demonstrate an understanding of quantity concepts (e.g. one, all),gender specific pronouns (e.g. her, his), picture analogies (e.g. you sleep in a bed, you sit on achair) or categories of objects in pictures (all the things we eat). She did not make inferenceswhen she was presented with an outcome and several pictures of situations that may haveresulted in that outcome (e.g. Charlie's shoes got all wet - what do you think it was like outside?raining).

Expressive Language Skills:The expressive language section of the PLS-4 is used to determine how well a childcommunicates with others. Preschool-age children are asked to name common objects, useconcepts that describe objects and express quantity and use specific prepositions, grammaticalmarkers and sentence structures. Formal language testing revealed a significant delay inWinona's expressive language skills with a standard score of 64 and a corresponding percentilerank of 1. She sought attention from others. She answered "what" and "where" questionsappropriately (e.g. what is she holding? "pillow"). She used an Is! to mark for regular plurals(e.g. blocks). She used a variety of nouns, verbs, modifiers and pronouns in spontaneousutterances. She produced basic four to five word sentences. She named a variety of age


appropriate pictured objects (e.g. scissors, monkey). She used quantity words when she wasasked to count items in a picture. Winona did not use the present progressive form of verbs(e.g. eating) or an /'si to mark for possession (e.g. cat's) She did not use words that describephysical state (e.g. hungry, thirsty). She did not answer questions logically (e.g. what would youdo if your hands were dirty) nor did she answer questions about hypothetical events (e.g. whatshould you do if you feel sick). She did not complete analogies (e.g. noodles are for eating, milkis for).

Language Sample:A language sample was collected yet could not be accurately analyzed as Winona's intelligibilitywas significantly compromised by speech sound production errors; particularly in connectedutterances. The evaluator relied on contextual cues and her foster mother's translations inorder to infer Winona's meaning. Some of her utterances are transcribed below and translatedwhen possible:

• Ah pida (where pizza)• Ah da baby (where the baby)• Ah dah nah working (...that not working)• Ah bah dow (...push down)• Iz a baby barah (it's a baby pillow)• Ka peez (cup please)• Look a kahpi• A din a deeza• Waeeoff• Ei geh off• A barah (a pillow)• Wa go oudai (wanna go outside)

Social Language:According to the language sample checklist of the PLS-4, Winona's pragmatic skills duringtoday's evaluation splinter into the 3-4 year old age range. She told about an object. She usedlanguage to control another person's behavior. She used language to interact with others.Winona did not talk about events or recent experiences. She did not maintain a conversation.

GFTA-2 and KLPA-2:

Articulation:The Sounds-in-Words section of the GFTA-2 provides several summary normative scores. TheGFTA-2 standard score provides a means to compare one individual to another based on ageand gender. A percentile rank indicates the percentage of individuals in the population thatperformed at or below a particular score. The percentile is derived from the standard score andit permits us to determine an individual's position relative to the reference group. The Sounds-in-Words section was administered on 11/3/09. Winona's standard score of 60 representsperformance on the GFTA-2 Sounds-in-Words section at the 3rd percentile of females her ageand is considered to be in the significantly below average range.


Speech sounds are mastered developmental^ in a typical order as people grow and learn. Alarge and well-controlled sample allows valid judgments about individual performance indevelopmental acquisition of sounds. A criterion of 85% was used to determine significance andneed for planning. In other words, if 85% or more of Winona's age or age and gender peershave mastered a sound in a specific position and Winona has not, then it may be a sound thatrequires intervention. The following table lists the sounds produced incorrectly or omitted byWinona and the percentage of her age and gender peers that successfully articulate the sound.

GFTA-2 Developmental Norms

Sound Position

/mlIVIdl

/ng/nil\lIblKlId/N

/ten//dch/

InitialMedialMedialMedialMedialMedialMedialFinalFinalFinalFinalFinalFinal

% Mastery of Sound

Gender Total96%92%92%89%92%92%87%94%87%90%83%87%87%

Population Total94%95%90%87%91%96%76%89%89%84%87%79%84%

Phonology:The Khan-Lewis Phonological Analysis-Second Edition (KLPA-2) is a norm-referenced analysisof an individual's speech development and phonological process usage. The analysis is used toidentify frequency of usage of ten distinct phonological processes grouped into three categories(Reduction Processes, Place & Manner Processes, and Voicing Processes), and any otherprocesses used by the individual. The KLPA-2 requires the administration of the 53 targetwords of the Goldman-Fristoe Test of Articulation-Second Edition (GFTA-2). The target wordsare analyzed for any sound changes and the sound changes are classified by phonologicalprocess. The total number of sound changes is converted into a series of scores based on age-and gender-based norms.

The Khan-Lewis Phonological Analysis-Second Edition (KLPA-2) was administered on 11/3/09.Qualitatively, the examiner's impression of Winona's overall intelligibility is poor. Quantitatively,when compared to her age and gender peers, her raw score converts to a standard score of 49and reflects overall intelligibility at or better than <1% of females her age which is in thesignificantly below average range.

The following developmental phonological processes were exhibited:

ProcessDeletion of Final ConsonantsSyllable ReductionStopping

% of Occurrence27(WNL until age 3.0)31 (WNL until 3.0)45 (WNL until age 3-5)


Process % of OccurrenceCluster Reduction 73 (WNL after age 3)Liquid Simplification 23 (WNL after age 3)Velar Fronting 21 (WNL after age 3)Palatal Fronting 22 (WNL until age 3)Deaffrication 50 (WNL after age 3)Initial Voicing 42 (WNL until age 3)Final Voicing 13 (WNL until age 3)

Winona was intelligible to the evaluator approximately 75% of the time in connected speechwhen contextual cues were available and less than 50% of the time in unfamiliar situations.

Winona's consonant speech sound production ability and her phonological process usage areboth in the significantly below average range.

*Please note that transcription is in the standard alphabet in order to better illustrate how thewords sound for persons unfamiliar with the phonetic alphabet.

INTERPRETATION OF INFORMAL ASSESSMENTS:

Oral Motor and Feeding Skills:Oral motor skills were assessed via parental reports. Ms. ttMfcMfcreported that Winonatolerates foods that vary in taste, texture and temperature. She drinks from a sippy cup, opencup and straw. She does not use a pacifier or suck her thumb for comfort. Upon informalobservation, all oral peripheral structures were symmetrical and had adequate range of motionfor speech and vegetative purposes.

Overall, oral motor skills were age appropriate.

Audition:Winona responded to speech and environmental sounds presented bilaterally. Please refer tofull audiological evaluation included as part of her CPSE packet for comprehensive informationregarding hearing status.

Voice:Winona presented with a slightly hyponasal quality to her voice that appeared to be the result ofnasal congestion. Otherwise, her vocal parameters were appropriate for her age and gender.

Fluency:Winona produced multi-word phrases fluently during this evaluation.

SUMMARY AND RECOMMENDATIONS:

Winona presents as a delightful, social and engaging child. Formal language testing via thePLS-4 reveals a significant delay in Winona's receptive language skills with a standard score of65 and a corresponding percentile rank of 1. Expressive language skills are comparable with astandard score of 64 and a corresponding percentile rank of 1. Winona's total languagestandard score is 61 with a corresponding percentile rank of 1. Winona's standard score of 60and percentile rank of 3 suggests a significant delay in her articulation skills as per the GFTA-2.


Winona's standard score of 49 and corresponding percentile rank of <1 indicates a significantdelay in phonological process usage as per the KLPA-2. Oral motor skills are adequate forspeech and vegetative purposes. Hearing was formally assessed by the audiologist (pleaserefer to audiological evaluation included in this CPSE report for comprehension regardingWinona's hearing status). Voice is adequate for Winona's age and gender; a slight hyponasalquality was noted that appeared to result from nasal congestion. Multi-word phrases areproduced fluently. Syntax could not be accurately assessed secondary to limited intelligibility.Pragmatic skills are grossly age appropriate.

Winona's scores suggest a significant delay in her speech and language skills at this time.Eligibility criteria are met for services through her school district's CPSE program. It was apleasure working with Winona and her foster mother during today's evaluation. Ms. Carbone isencouraged to call any provider working on her evaluation team at any time with questions orconcerns.

This recommendation is to be considered within the total decision making context of the CPSEmeeting where actual determination of services is made.

Lisa Valenti, MACCC/SLPSpeech Language PathologistLicense #: 007745

**l certify that I personally evaluated the above named child, employing age appropriate testinginstruments and procedures as well as informed clinical opinion. I have discussed the results ofthis evaluation with the family. The family was also given Just Kids' contact number should theyhave any questions.



Cathy CtanfiranoDirector of Children's Services

Middle IslandLongwood RoadP.O. Box 12Middle Island. NY11953(631) 924-0008 Phone(631)924-1243 Fax




j JUST KIDS£ Early Childhood Learning CenterUl

Audiological Evaluation

< Name:UD.O.B.:

Winona Piscitelli7/6/05

Date:Examiner:

11/3/09Diane Davis, AuD, CCC-A

Winona Piscitelli, age 4 years 4 months, was seen for an audiological evaluation on11/3/09. She was accompanied by her foster mother who acted as informant. Shereported that she does not feel Winona is exhibiting hearing difficulties. She stated thatWinona was recently seen by her physician and she had some middle ear fluid. There arereported concerns about Winona's articulation.

Results

Results of play audiometry were considered to be of good reliability in indicatingnormal hearing sensitivity from 250-4000 Hz in both ears. Speech reception thresholdswere in good agreement with pure tone findings at 15 dBHL bilaterally. Speechdiscrimination ability was excellent at 92% in each ear.

Tympanometry testing revealed normal middle ear systems compliance and normaltympanic peak pressure (Type A) in each ear.

Summary

Winona is exhibiting normal hearing sensitivity from 250-4000 Hz in both ears.Speech reception thresholds were normal and speech discrimination ability was excellent ineach ear. Tympanometry testing was suggestive of normal middle ear function bilaterally.There are no further audiological recommendations at this time.

Diane Davis, AuD ,CCC-AAudiologist

DDgl

JUST KIDS s~Diagnostic and Treatment Center Inc.

Longwood Road • Middle Island • New York • (631) 924-0008Mailing Address: P.O. Box 12 • Middle Island • New York 11953

AUDIOLOGICAL TEST INFORMATION

NAME DATE / /"

PURE TONE AUDIOMETRY (ANSI)

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Cathy CunfaranoDirector of Children's Services

Middle IslandLongwood RoadP.O. Box 12Middle Island. NY11953(631)924-0008 Phone(631)924-1243 Fax

Lindenhurst887 Kellum StreetLindenhurst, NY11757(631) 884-3000 Phone(631) 884-1959 Fax

Rlverhead556 East Main StreetRiverhead, NY 11901(631)369-1927 Phone(631)369-1957 Fax



Occupational Therapy Evaluation

Date: November 6, 2009Evaluator: Lisa Lanzarotta, OTR/L

< Name: Winona PiscitelliDOB: 07/06/05CA: 4 years 4 months

Introduction:

Winona is a 4 year 4 month old girl who was referred for an occupational therapy -•-evaluation due to concerns of fine motor coordination delays and sensory processingdifficulties as it impacts on function. This evaluation was approved by the taHgMMr*school district and will assist in determining eligibility criteria under the provisions of section4410 of the education law. J"his_evaluation was conducted at Winona's pre-schooljfc

jflMMHer foster mother, BJMMHIfe was present for the evaluation. The purposes andprocedures of this evaluation were explained to Ms.*AHHIfc«nd the consent was signed.

Behavioral Observation:

Winona was tested in an empty classroom with her foster mother present. Shehappily greeted the evaluator and she was easily directed to the table for standardizedtesting. When she entered the room Winona was already engaging in coloring with amarker and paper. With some verbal prompting she was directed to table top testing.During most testing items Winona preferred to stand rather than sit. Occasionally sherequired rewards with stickers to engage in activities such as block design imitation.Winona appeared distracted at times, however she presented with a runny nose due to acold. Ms. flrtMBreported Winona was slightly out of sorts due to having a cold. Withverbal prompting, praise and rewards Winona did engage in all presented tasks. When shedid engage in any particular task she focused well carrying the task through. Testing itemsthat required only a verbal directive, such as folding paper, Winona had difficulty performingthe task. When a visual demonstration was provided Winona was then able to completethe requested task.

Evaluation Methods:

Winona was evaluated using the Peabodv Developmental Motor Scales-2nd (PDMS-2). Test of Visual Motor Skills-revised (TVMS-R), Sensory Profile- caregiver questionnaire,clinical observation, therapeutic handling, and parent report.

Orthopedic/Neuromuscular Status:

Winona's muscle tone appeared in low-normal ranges throughout trunk and upperextremities. Her muscle strength appeared within good ranges grossly throughout basedon observation of play with novel toys and movement within her environment.Winona's vision appeared adequate for the purposes of this evaluation. She appeared tohear localized sounds but she responded well to her name. Protective reactions werepresent. Her righting and equilibrium reactions were present and incorporated into dynamicmovement.

Winona Piscitelli Occupational Therapy Evaluation Page 2

Winona ambulated independently. She jumped in a forward motion with two feettogether. She was able to hop on one foot unsupported and hop in a forward direction. Winonawas unable to stand on one foot unsupported. She was able to weight shift in order to kick amoving ball. Winona was able to throw and catch a ball. Ms. Carbone reports Winona is able topedal a tricycle. Winona's gross motor skills appear within age limits based on informalassessment through clinical observation.

Fine/Visual Motor Skills:

The PDMS-2 was administered to assess Winona's current level of fine/visual motorskills. Areas assessed were grasping; the way one holds and manipulates objects and visualmotor integration; the way one use their eyes and hands together for task performance. ThePDMS-2 revealed the following scores:

Skill

Grasping

Visual MotorIntegrationFine MotorQuotient = 88

StandardScore

7

9

PercentileRank16th

37m

21st

StandardDeviation-1.0

-0.5

-0.8

Range

6-7

8-12

80-89

Description

BelowAverageAverage

BelowAverage

Winona appears to have a right hand preference as she held and manipulated mostobjects with using her right hand. She is utilizing a dynamic tripod hold on a marker and pencil.Winona uses a neat pincer grasp when picking up small objects such as beads and cereal. Sheuses a 3-jaw top hold on cube blocks. Winona uses an appropriate thumb up hold on ascissors. She is not yet able to manipulate buttons to open and close with just a verbaldirective. With a visual demonstration Winona did open a button.

In terms of Winona's visual motor skills, she copied a closed circle (33-34 months) onher second trial. She demonstrated decreased accuracy to copy a cross (41-42 months) as theintersecting lines were more than twenty degrees from the perpendicular. She required twotrials to copy a cross. Winona drew a circle in her attempts to copy a square (49- 50 months).She was unable to imitate a square. She could not carry out the verbal directives to connecttwo dots with a line (53-54 months) and she responded with drawing circles around the dots.Winona was able to build a nine cube block tower (29-30 months). She exhibited good visualperceptual skills Winona with imitating block designs such as a bridge (31-32 months), a walldesign (35-36 months), replicating steps (51-52 months) and a pyramid (53-54 months).Winona approached scissors with a pronated hold to cut across paper (37-38 months). With thevisual cues of lines she was able to use a thumb up hold on scissors. She was able to cut alonga line (41-42 months) within a 1/2" of the line. However her cuts were choppy. Cutting outshapes was a challenge for Winona. She did attempt cutting a circle (49-50 months) and asquare (53-54 months), but was unable to complete the tasks with coordination both handstogether well.

Winona was able to string beads (27-28 months) with good coordination and control.She laced a strip by following a running stitch (39-40 months). Initially she laced incorrectly, but


recognized her mistake and then self-corrected. She was able to drop small pellets into a bottleone at a time within 30 seconds (41-42 months).

The TVMS-R was also administered to further assess Winona's design copy abilities asshe exhibited difficulties with copying a cross and a square on the PDMS-2. Design copy is aprerequisite to letter/number formation, writing and reading. This test isolates design copy andassesses eight classifications of visual-motor perceptual skills: closure, angulations,intersection, sizing (gradation), rotation/reversal, line length, over/under and modification.Therefore can further illustrate and identify areas of weakness. When tested with the TVMS-R.Winona demonstrated difficulties with sizing (gradation), line length, rotation/reversal andover/under modification. Winona did not complete all designs. Designs such as a double circle,an oval, a rotated "T", an "L", rectangle, three small squares and a triangle were challenging forWinona. According to the TVMS-R. Winona received the following scores: Standard Score: 68,Percentile Rank: 2nd, Standard Deviation: >-2.0.

Sensory Status:

Mrs.«^BHptwas provided with the Sensory Profile- careqiver Questionnaire to provideinformation regarding Winona's sensory processing abilities. Sensory processing is the wayone takes in information from the environment and his/her own body, registers the information,interprets the information, organizes the information and produces an adaptive response. TheSensory Profile reveals three area of weakness with Winona's sensory processing abilities. Shereceived a Probable Difference score (=/> -1.5 SD below the mean) in Touch Processing,Emotional/Social Responses, and Behavioral Outcomes of Sensory Processing.

Winona is described to frequently respond negatively to hair washing. Ms.4MMHlereports that Winona does not like the water running down her face associated with hair washing.Occasionally, Winona will become irritated with wearing shoes and socks and prefers to bebarefoot. Reportedly Winona will occasionally awake during the night crying and possiblyhaving nightmares. She will tend to cry easily and she frequently has difficulty toleratingchanges in plans routines. Clinical observation noted distractibility; however Winona wasredirected with minimal effort. The Sensory Profile indicates minor difficulties with processingsensory information with over responsiveness noted.

Self-Care Skills:

The following information was obtained via interview with Ms. 4HHtet ReportedlyWinona drinks from a straw and an open cup. She uses a spoon and a fork independently withsome spilling. She can pour a drink from a pitcher. Winona can doff shoes, socks, coat andpants. She has emerging abilities to don socks and shoes. She can wipe her nose with atissue and wash her hands.

Evaluation Summary:

Standardized testing with the PDMS-2 reveals Winona's fine/visual motor skills arewithin normal limits. Her fine motor quotient was an 88 with a standard deviation of -0.8 belowthe mean and placing her overall skills in the 21st percentile. The TVMS-R reveals significantdelays in the area of design copy. She received a standard score of 68 revealing a standard


deviation of greater than -2.0 below the mean. The Sensory Profile reveals delays with sensoryprocessing. These sensory processing delays do not appear to impact skill acquisition.

Overall results of testing indicate that Winona presents with generally age appropriatefine motor skills. She evidenced some slight difficulty with cutting out shapes and she requiredvisual demonstration to perform several tasks. She uses a mature grasp on a writing implementand demonstrates good graded control. Significant difficulty was noted with design copy,however, this may be due to limited exposure to these types of tasks. At present, Winona doesnot appear eligible for OT services. A re-evaluation in 6 months is recommended shouldWinona continue to display difficulty with copying graphomotor designs.

Final determination of eligibility criteria and frequency of services is made by the CPSE.

6TTL/LLisa Lanzarotta, OTR/LRegistered Occupational TherapistLicense #-009510-1

OCT.15.2009 14:06 281211810/15/2009 13:02 FAX 631 924 42

of. en ..:

PED ADOL Shirl

JUST KIDS D AND T

JUSTKIDSan. early childhood learning center

Soad « Middle-inland * Heir York » (516) 92«-0008Address; P.O. Bo* J2 ° Widdl* isiand « New *wh .US53

Date of Birth:

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Past- Medic? 1 -History:

Hospitalize tions:

Allergies:

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Abdomen ;

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Heart:

Lungs:

Genito Urinary:

Wusculoskeletal:

Nearoloaical:

Medical Diagnosis:

Current Medical Ccndition: . r

Current Medication: ••

Activity Restrictions;.

Date of Ixaninatian:

Physician's'Nurse Practitioner;

. Typed or Printed Name;

Addr ess:

OCT.15.2009 14:06 281211810/15/2009 13; 02 FAS. 03.1 924 42'

PEE ADOL Shirl

JUST KIDS D AND T

JUST KIDSan early childhood learning center

Lungwort Road <= Middle island « New York ° |SJ6) 924-OOOaP.O. 0<K 12 .

#4593 P.003 7004

(21003

Child's W.«:

DPT.-Mr. -of Birth:

Tuberculin Test; Typ«*: Date:

Lead Scree ilng-Xbate: Result:

.Result:

Physician1 :/Nurse .Praictltianar'

Data;

Address:

Phone

OCT.15.2009 14:06 2812118 FED ADOL Shirl #4593 P.004 /004

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STEVE LEVYSUFFOLK COUNTY EXECUTIVE

DEPARTMENT OF SOCIAL SERVICES

Date: 10/1/09

Dr. Penzer990 Westbury Rd., Ste. 100Westbury,NY 11590

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GREGORY J. BLASSCOMMISSIONER

RE: Winona Piscitelli, dob: 7/6/05

Dear Sirs/Madam:

Please find enclosed medical/school release in reference to the above-named client(s).

We would appreciate your forwarding all pertinent information regarding this family tothis agency, in care of the undersigned, at your earliest convenience.

If you have any questions, please feel free to call me at 854-9139.

Thank you for your attention to this matter.

Very truly yours,

Lisa ScafideCaseworker, Team 63/102

Robert LetoSupervisor, Team 63/101Child Protective Services

If school:

PsychologicalPsychiatricAttendanceGrade-Academic PerformancePeer and social relationshipsMedical and/or hygienic informationProgress reports

If medical:

Specific informationAll medical recordsAny concernTreatmentAttendance

BOX 18100 HAUPPAUGE, N.Y. 11788-8900 (631) 854-9935

Patient Information

Name:

Authorization for Release of Protected Health Information (PHI)

Date of Birth: Q- L? -Q

<o(p.o fir/00Address:

I hereby authorize the use and/or disclosure of my protected health information as described below. Iunderstand that this authorization is voluntary. I understand that if the organization authorized to receive theinformation is not a health plan or health care provider, the released information may no longer be protected byfederal privacy regulations.

To: (Name and address of person, facility, and/orprogram disclosing information)

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Kry

From: (Name, address and title of person and/ororganization to which disclosure is to be made)

Child Protective Services TEAM# 63/102P.O. Box 18100Hauppauge, New York 11788-8900

Treatment planDates of treatment

I I Discharge summaryrecord/Other:

576?- 333-tInformation to be released: (Check applicable categories)

I I DiagnosisI I Psychological/Psychiatric evaluationI I Laboratory & X-ray reports/resultsI I Medical history

Purpose or need for protected health information: Child Protective Services Investigation/ provision of services.

I understand that the above information is protected by Federal Regulations 42 CFR, Part 2, "Confidentiality ofAlcohol and Drug Abuse Patient Records" and cannot be disclosed without my consent unless otherwise providedfor in the regulations. I understand that I may revoke this authorization at any time by notifying the providingorganization in writing, but if I do it won't have any effect on any action they took before they received therevocation. I understand that this permission will expire when acted upon, or ninety (90) days from this date,whichever comes first.

Print Name:

Signature: Date:

If this authorization is signed by a personal representative on behalf of the individual, complete the following:

Personal Representative's Najrne:

K L;> CPS

Signature:

Relationship to Individual:/ ^

You are entitled to a copy,of this authorization after you sign itRelease of Information-Alcohol an J Drug Abuse Patient Records-Revised (5/04)

03/31/05 - CS

Vaccine Administration Record

Patient Name:

Birth date:

Record #:

7-6 -CS"

N.Y. State Eligibility Code:Paul H. Penzer. M.D.. P.C.Paul H. Penzer, M.D., F.A.A.P.

Michael J. Everoskl, M.D., F.A.A.P.Jeanette Alvarenga, D.O., F.A.A.P.

990 Westbury Road, Suite 100Westbury, New York 11590

Telephone: (516) 333-4100 e Fax: (516) 333-4255"I have been provided a copy of the appropriate Centers for Disease Control and Prevention Vaccine Information Material(s) and have read, or have hadexplained to me, information about the diseases and the vaccines listed below. I have had a change to ask questions that were answered to mysatisfaction. I believe I understand the benefits and risks of the vaccines cited, and ask that the vaccine(s) listed below be given to me or to the personnamed above (for whom I am authorized to make this request)."

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PAUL H. PENZER, MD, PC, FAAPMICHAEL J. EVEROSKI, MD, FAAP990 WESTBURY ROAD, SUITE 100

WESTBURY, NY 11590(516) 333-4100

DATE: 12/28/05 ACCT#: 12790 DOB: 07-06-05 SEX: F

LAST NAME: PISCITELLI FIRST: WINONA OB:

of-ADDRESS: 318 ELLISON AVENUEH: 516 333-2672 W:

WESTBURY NY 11590

GUARANTOR:SPOUSE:

WINONA PALMIOTTI

PERINATAL HX:

FAMILY HX:

CHILD SOCIAL HX:

GROWTH & DEVELOPMENT:

SCHOOL OR BEHAVIOR PROBLEM:

SMOKING : no *- ALG :

SURG: 0ACC:

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DISCUSSIONS:W-WINDOW GUARDS:A-ALARM, SMOKEAIDS, ALCOHOL

S-SEAT BELTS, CAR SEATST-THERMOSTAT H20 TEMP<120E-EMETIC-IPECACSAFETY HOUSESAFETY BICYCLESAFETY WALKERSEXUAL ACTIVITY

Safety burns, falls, drowning I,rtsun, walker, poisons, water temp <CPR/Kirsi Aid/Choking

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W Jiild Examination (Birth to 6 Years of e)

7Age

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(See Atfeskedfor Failures) Titmus Pass/Fail

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UA (NegJ)Abn(See AttacEea for

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VIS providedYes / No

Pertinent Medical/Surgical History No Change Allergies

Changes in Family Medical or Social History No Change

Parental Concerns Raised None

Physical Examii

GeneralHeadEyesEarsNoseMouth/ThroatNeckChest/BackCardiacPulmonaryAbdomenPelvisMusculo skeletalNeurologicSkin

lationN A

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Assessment/Plan

Medications None

DevelopmentASQ Communication

Gross MotorFine MotorProblem SolvingPersonal/Social

(circled values indicate out of range)Results Discussed: Y NPatient referred: Y N

ASQ:SE \ \(circled value indicates out of range)Results Discussed: YPatient referred: Y

Guidance/CounselingMilestone ExpectationsSafetyDaycare/SchoolImmunizations

NN

NutritionCounseling

Current Food IntakeExerciseDiet PlanningRisk FactorsTarget weight goals (by date)Procedures:Ear CurettageEar Piercing:

GoldDiamond

Forms Filled out

Signature: Follow Up:

PRACTICE LIMITED TO PEDIATRICS & ADOLESCENT MEDICINE

Date Name \M * r\

Birth and Delivery: Normal CISNeonatal Problems at Birth: No Yes:

Date of Birth

Breech

Birth Wt:. Discharge Wt:Feeding: Breast Formula

Past Hospitalizations: NoneYes: »>v r

. Amount/.Or Time

Frequency

Serious Illnesses: NoneYes:

Medications: None. Yes.

rAlleigT53TTIgne

'

Age Health and/or Allergies

MotherFatherSiblingSiblingSibling

Family History

Ht Disease, M.I. or Stroke before age of 50: Yes

T.B. or T.B. contact: Yes NoDiabetes: Yes No

No

Other Significant Problems (patient or family)

Development

Sits

Stands .

Cruises

Walks _

Speech

Patient

Mother.

Father_

Freed, Sc^rz, Klecnberg, Nussbaum, F&*ta, L.L.P.& Associates

DOB

Home #.

Home #_

iiki^Work#

Work #_

00?Cell #

n«ll #

IMMUNIZATIONSDate Date Date Date Date

Pediarix

DTaP/DPT DTapgXDPTD'Pediarix D

DTsutff DPTD*PediarixD

DTap^T DPTD*PediarixDPentiel

DTap D DPT D DTap D DPT D

Proquad n

Varivax^a^Proquad n.

arivax #1 Varivax #2

lopfrfMenactra

Rotovirus #1 #2 #3

Flu VaccineInjD MistD

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Flu VaccineInj D Mist D Inj D Mist D Inj D Mist D Inj D Mist D

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Stature-for-age andWeight-for-age percentiles N; Record #.

Mother's Stature

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Date

in

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Nutritionwww.abbottnutrition.com

Pedialyte"Oral electrolyte maintenancesolution/freezer pops

Pedicure"Complete, Balanced Nutrition*

Nutritionally complete aminoacid-based medical food andinfant formula with iron

"SOURCE: Developed by theNational Center for Healthstatistics in collaboration withthe National Center for ChronicDisease Prevention and HeathPromotion (2000).

This chart is consistent with CDCgrowth data as of November 2007.

http://www.cdc.gov/growthcharts

O 2007 Abbott Laboratories Inc

U

ifl TUST KIDS%<

Early Childhood Learning Center

Sieve H f l dUxcculi'C Di rc r fo r

Sicplicn Cftrdon

B AUTHORIZATION FOR RELEASE OF INFORMATION

< Cl ilds Name: _J|Vj_

DCte of Birth:

>irccror of Children^ Service:

Middle UlantlP.O. Bux 12,Longwood RondVlicldle Island, MY11953;631) 924-0008 Phone;&31) 924-1243 F;ix

LiriJenliurstUB7 Kellvtm StreetLindenhurst, NY11757(631) 884-3000 Phone(631) 884-1959 Fnx

Rivcrlicacl540 East Main StreetRiverhead, NY 11901;f>3 1)369- 1927 Phone;e.ll) 369-1957 F;u

Hoyd

Shirley. NY 11 96 7631)7.81. .6800 Phone631 } 281 -6096 F»x

Records Requested: £0rtT>mU/WC gJUfofl)''*

I give permission for Just Kids Diagnostic and TreatmentCe nter to release and obtain such information as may benecessary to and from the following individual and/or agency:

Nc me:

Ac dress:

Tc wn :

Tclephone:

Tl is information may include record of medical, educational,pi ychological, social history," speech and hearing, andpi ysical and occupational evalua^TTori&v and/or therapy.

S: gnature:

Ac dress:

Parent/Lej^al Guardi)|JX

9

ster ParentdtDi

\10V

D; te:

-• - Just Kids Diagnostic and Treatment Center Use Only;

Cl ild is pending evaluationCl ild is currently pending placementCJ .ild is currently in programPi ease obtain informationP.' ease release informationn lofinfo.Iw

a child 6

Documents

significant

foster mother

language skills

motor skills

give consent

responds appropriately

appeared motivated

suite 100