NEW JERSEY EARLY INTERVENTION SYSTEM 2026

1. Click ‘Get Form’ to open the NEW JERSEY EARLY INTERVENTION SYSTEM Service Encounter Verification Form in the editor.
2. Begin by entering the Service Provider Agency Name and the LOA or Grant Number at the top of the form. This information is crucial for identifying your agency.
3. Fill in the names of both the Service Coordinator and Practitioner, ensuring you include their last and first names for accurate identification.
4. Next, input the Child’s Last Name and First Name, along with their Date of Birth (DOB) and Child ID#. This section is vital for linking services to the correct child.
5. Specify the Service Type by selecting from options such as Evaluation, Assessment, or Therapy types. Ensure you also indicate the Service Location using provided codes.
6. Record the Start Time and End Time of service, calculating Total Time to report it accurately to the nearest 15 minutes.
7. Finally, ensure that a Parent/Caregiver Signature is obtained to verify services received. Remind them not to sign if any information is incomplete or inaccurate.

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