Philadelphia County Service Agreement



  • Parent/Caregiver Name

  • AND EBS Early Intervention

  • Child's Name & Childlink Number


  • We at EBS Early intervention serve young children with developmental needs and their families. Through our services, we want to guide and support you so that you can help your child grow and develop in the best ways possible. Teachers (special instructors), therapists, and other Early Intervention personnel will make regular appointments with you to come to your home or the community setting in which your child spends his or her time. Because you know your child best and are truly his/her best teacher, it is very important that you work actively with the Early Intervention service providers and participate in the services your child receives through Early Intervention.

    This agreement and its provisions will clarify for all participants the expectations for open and frequent communication. The Agreement:
    • Outlines the responsibilities of the family/caregiver and provider
    • Establishes the provider's commitment to provide uninterrupted services through careful planning and anticipation of need whenever possible
    • Is a tool for open discussion regarding a family's ability to keep scheduled appointments

  • I. We want to make sure that each family understands that:
    1. Services will be delivered in the natural environment, and in most situations this will likely be in your home.
    2. There will be no make-up for visits missed when parents/caregivers do not inform service providers in advance of cancellations or unavailability.
    3. In the case of three consecutive visits missed (with the service coordinator and/or service provider), without advance notice, your child may be discharged from the specific service missed, or from early intervention services overall (in cases where visits are missed for all services provided).
    4. If you are unhappy with a specific provider offering services to your child, you have the right to request a change of providers.

  • II. You, parent/family member/caregiver of child named above, agree to:
    1. Keep scheduled appointments and actively participate in them.
    2. Call the Therapist if you are not able to keep a scheduled appointment.
      Please call as soon as you know this. We understand that emergencies come up, and we are glad to be as flexible as possible to meet your needs. Remember that you can leave a message with your EBS program coordinator Ashley Cyr at 800-578-7906 ext. 284, 24 hours a day.
    3. Promptly tell the service provider and your Child Link Service Coordinator of any changes in phone number or address.

  • III. Therapist/Educator agrees to:
    1. Set up appointments with you for (relevant El services) that are on your child's Individualized Family Service Plan (IFSP). The appointment dates and times will be worked out with you to best meet your schedule.
    2. Keep regular appointment times with you. We will let you know of any changes as soon as possible, such as a therapist being ill or a teacher taking vacation time.
    3. Plan to provide services without any interruptions. If we know ahead of time that a therapist, teacher or other home visitor is not going to be able to keep an appointment or is going to be away for a while, we will work with you to make other arrangements.
    4. Help you find other services for your child, when your child's team agrees that this is best for him/her.
    5. Work closely with your Childlink service coordinator.

  • We very much want to provide support and services to you and your child. We can only do this, however, with your regular participation. We may not be able to continue services if there are two missed appointments that you did not cancel ahead of the appointment time. If this should happen, the following will occur:
    1. We will contact you through phone calls, letters, and other means in order to talk with you about your interest in continuing the specific service(s) noted on your IFSP.
    2. If we do not hear from you within 7 calendar days from the date of our first letter and phone calls, or 7 calendar days from the date of the second letter (with no contact in between), your child may be discharged from the service provided (or early intervention services overall if all services are affected). We will notify you in writing of the discharge.
    3. Your service coordinator will contact you separately to determine if, perhaps, you are interested in changing service providers, or whether or not you are interested in receiving early intervention services at all at this time. You and your child may want to participate in El services in the future.

  • I understand that all Child Link staff and El service providers are mandated reporters of child abuse and neglect according to the Child Protective Services Law (23 PA.CS., Chapter 63) and regulations in Chapter 3490 (relating to protective services). If at any time the Service Coordinator or any early intervention service provider suspects that child abuse or neglect has, or is occurring, or that my child is at imminent risk for abuse and/or neglect, they are required by law to report this suspicion. In every situation, the service providers will share their suspicion or concern with me in advance, and the necessity to report.
  • MM slash DD slash YYYY


  • NOTE: The provider representative has carefully reviewed this agreement with the parent/family member/caregiver, and made certain that the person signing the agreement understands all of it. A copy of the signed agreement will be given to the parent/family member/caregiver and a copy will be retained for the provider file.

  • To be signed after form submission