A CHILD 5

MENTAL HEALTH CLINICS (cont)

Family Counseling Service: -

Shirley 399-9217464-10 William Floyd Parkway, Shirley, NY, 11967

Hampton Bays 728-7232154-5 Montauk Highway, Hampton Bays, NY, 11946

Farmingville Mental Health Center.. 854-255215 Horseblock PLFarmingville, NY, 11738

Family Service League:

East Hampton Center 324-334466 Newtown Lane, East Hampton, NY, 11937

Hampton Bays Center 723-2316225 West Montauk Highway, Suite 4, Hampton Bays, NY, 11946

Mattituck Center 298-8642755 Main Road, Mattituck, NY, 11952

Family Wellness Center (FREE) 851-3810120 Plant Avenue, Hauppauge, NY, 11788

PEGS Mental Health Centers:Long Island Call Center 1-(516) 364-0794

Center Moriches Center 874-2700220 Main Street, Center Moriches, NY, 11934

Central Islip 234-7807115 Carleton Avenue, Central Islip, NY, 11722

Madonna Heights Services 643-8800151 Burrs Lane, Dix Hills, NY, 11746

14

JUST KIDSEarly Childhood Learning Center

Steve H.:ldExecutive D ireetor

Sreplten CordonDirector

Cathy CianfiranoDirector ol Chi|dn.-n's Services

Middle IslandP.O. Box 12,longw ood RoadVliddte bland, NYLI 953631) 924-0008 Phone631) 924-1243 Fax

,indcnhurst;87 Keljum Stree-.indenhurst, NY1757531) 884-3000 Phone531) 884-1959 Fax

jvcrhcad40 East Main Streetiverhead, NY H'901131} 3694927 Phone131) 369-1957 Fa:.:

Illiaffl Floyd1 Lexington Roadurley, NY 1196731)281-6300 Phone31) 281-6096 Fax

: hereby give consent to have my child, W j1 fjDfifl. rI^>U *Q »^<valuated by Just Kids in the following area(s) and with the1ollowing measures: ,

Speech/Language Evaluation

( -7( )

( )( )( )( )

( )( )

Preschool Language Scale - 4 (PLS-4)Clinical Evaluation of Language Fundamental)? - Preschool (CELF-P)Goldman-Fristoe Test of Articulation - 2 (GFTA-2)Kahn-Lewis Phonological Analysis - 2 (KLPA-2)Receptive-Expressive Emergent Language Scale - 2 (REEL-2)Expressive One-Word Picture Vocabulary Test - Revised (EOWPVT-R)Receptive One-Word Picture Vocabulary Test - Revised (ROWPVT-R)Rossetti Infant/toddler Language ScaleOral Motor Eating Evaluation (Morris)Oral-Peripheral Examinationan'juage SampleFruiting's Stages for Acquisition of PragmaticsWesi:by Symbolic Play ScaleStuttering Prediction Instrument (SPI)

Audiolcgical

I have been informed about the purpose of the evaluation andtie. methods to be used. I have received my Due ProcessRj g-hts.

Date

) I do not consent to the evaluation(s) requested above

Paient Signature

(cisp)

Stive Hd<tExecutive

kqpbtn Gor&ttDinatu

Cadty

Director of Children1!; Service*

Middle IslandLong wood F.oadP.O. Box 12Middle Island, NY11953(631) 924-OClOg Phone(631)924-1243 Fu*

Luideohurst88? KeUvuti StreetUodcnhurst, NY11757(631) 884-3000 Phone(631) 864-1959 Fax

Riverhead555 East Mam StreetRiverhead, NY 11901(631) 369-1927 Phoria(631) 369-1957 Fax

William Floyd99 Laxingtor; RoadShirley, NY 11967(fi31)2Bl-6BCOPhonf.'(631) 281-6096 Fa>:

Early Childhood Learning Center

I hereby give consent to have my child, W I Y\ DV\* f1<^1 TCI Ifvaluollo

( ./; Psychological Evaluation:

evaluated by Just Kids in the following area(s) and with the4 following- measures;

( )

JBayley Scales of infant Development: Third Edition (BfilD: Il'I)'Wechsler Preschool and. Primary Scale of Intelligence-Third,Edition (WPPS1-III)Stanford-Bins!: Intelligence Scale; Fifth .Edition (SBIS:V)i/ineland Adaptive Behavior Scales; Second Edition (VABS;I1)Conner's Rating Scale (CTR.S, GPRS) - - •-Achenbach Child Behavior Checklist (CBCL)Aehenbach Caregiver-Teacher P.eport Form (CTRF)Childhood Autism Rating Scale (CARS)cjilliam Autism Rating Scale (GARS)Behavioral Assessment System for Children (BASC)Other

( ) Educational Evaluation:

( ) Michigan Early Intervention Developmental Profile (EIDP)( ) Early Learning Accomplishment Profile (SLAP)( ) Bracken Basic Concept Scale - Revised( ) Peveiopmental Assessment of Young Children (-DAYC)( ) Brigance -Inventory of Early Development - Revised( ) Mullen Scales of Early Learning (MSEL)

( ) Audiological

( -w^ Social History

I have been informed about the purpose of the evaluation andzhe methods to be used. I have received my Due Processlights,

, c

Date

) I do r.ot consent to the evaluation(s) requested above.

Parent Signature

c fpsyed

Date

Cenfter

I hereby give consent to have my child,g e\ aluated by Just Kids in the following area(s) and ^with the

u fo l lowing measures-.Held

.Stephen GordonDirccrol

tci:or o/ Children's .scrvicr?

Idle IslandBox 12,

.die Wand, NYi3) 924-0008 Phone:) 924-1243 Fax

enhurstKeOum Streetifrihurst, NY7i 884-3000 PhoneSS1.-1.9S9 Fax

-head;.ast Main Street•bead, TvA'1 11901369-1927 Phone369-1957 Fax

mi Floydxington Roady, NY 11967281-SSOoPlione281-6096 Fax

Occupational Therapy Evaluation

( ) Michigan Early Intervention Developmental Profile (EIPP)! **7 Peabody Developmental Motor Scales (PDMS-2)( ) Beery-Bukteniea Test of Visual Motor Integration (VMI)(^"} Gardner Test of visual-Motor Skills (TVMS)( ) Gardner Test of Visual-Perceptual Skills (TVPS)( vf Dunn & Westman Sensory Profile

,-, ' ,-., ( ) Mill'er Assessment for Preschoolers (MAP)\ , ;•*! ' ( } DeGongi-Berk Test of Sensory IntegrationX'' ( } BruninXs-Oseretsky Test of Motor Proficiency

( ) other

( ) Physical Therapy Evaluation

••.{''! Michigan Early Intervention Developmental Profile (EIDP)._-.•• ' ( ) Early Learning Accomplishment Profile 1ELAP)

-tfy- ( } Learning Accomplishment Profile (LAP)t, \" ( ) Peabody Developmental Motor Scales (PDMS-2)

.,,','' ' ( ) Pediaciric Evaluation of Disability Inventory (PEDI)\S*H •.'". ( ) Other\^ . .

%f-'' : ' ' • ( ) Vision Therapy Evaluation

! ( )' Smith-Cote Functional Vision Evaluation( ) Low Vision Observation Checklist( ) Oregon Project for Blind and Visually Impaired Preschoolers( ) Diagnostic Assessment Procedure (DAP)( ) Other

I h ive been informed about the purpose .of the evaluation andthe methods to be used. I have received my Due ProcessRig! tar.

Date

1 do not consent to theabove.

Parent Signature

aluation(s) requested

Date

(cfp lot.03

-.Y..«W. „ ., , ,,.,.. , /.mjij., ,..,., ;,.,

M.LX,r-.A.A.P.

-M.D., F.A.A.P.ID., F.A.A.P.. 'D.O., F.A.A.P.

And AssociatesPRACTICE LIMITED TO PEDIATRICS & ADOLESCENT MEDICINE

DATfirJOllLCB

NUMBER OF PAGESINCLUDING COVER:

WARNING; THIS TRANSMTTTAL CONTAINS PRIVILEGED AND CONFIDENTIAL,IN FORMATION INTENDED FOR USE D Y THTi RECIPIENT N A MED ABOVE. USH,

COPY, OR ['JtSTRlBUTINC TO ANY OTHER PERSON IS STRICTLY PROHIBITED. IFYOU HAVE KRCEIVEU THIS TRAMSMTTTAL IN ERROR, PLEASE NOTIFY US

LVTMEI5IATELY BY m,EPHONE, AND RETURN THJ5 MISDIRECTEDTRANSMTiTAL TO US BY FAX OR MAIL AT THE NUMBRR ABOVE.

Pa.tieiit NameJUJ n&

Pulsc Oi Sat

Chief Com pla Pertinent IVfccl/Surg History None

family/Social lli-itory No ChangesDay care Ye.s/NoSmoke l:xposiu-c Yes /NoOthei;;

' tReview oi ,>yst-CJ

HFENTKespCardiciGIOrlhoNeuroPsychfeedingSleep/fatigueWeight ChangeFevers

Physical F.vamin

GeneralHeadEyesEars'NoseMouth/ThroatNeckChest/BackCardiacPulmonaryAbdomenPelvisMusculpskeleialNeuro log joSkin

Assessment/Plan

tlN

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C//•LS

•.-''

•^

<*^"SZs -- • \ / \ / \/ \ / 1-1^ "••" •""" ' » ^'"'" " — v V V T .' , ImmuuiziitioHS Up To Date Yes / No

1. OOMM ' / H Allergies (^L^>

>— ! / \t"^\l\~T '///I -..,fT.-UM I'J ' //Cf McdUations N«me

Â/^ 7<^^ r V f" C">_yL.c>

ProceduresEan'rri«ationWarl RemovalFhiorcsceia Eye ExamTympanomelryHearinK TestVision TestiriKUriue Catheleri7,ationSpirornetjyLabs

j Dextrose Slick#,4^.. (JL A *~ $£•*.- X! ^X- - Heuic-occult Nejj/Pos

'/r t\./-e-S-*-f <r<f-?,-/7/j**~-- •Hemoglobin I ]Rapid Strep Neg / PosRapid Influenza Nefi / PosUrine Culture Neg / PosUrine Analysis Neg / Pos

(See attached, tor Positives)Urine R-I1CG 1 | Neg /PosNebulizer Treatments 1 2 3 4Xopenex 0.3 0.63 1.25Albuterol 1.25 2.5Pulmicort .25 .5 1SuppliesSterile GlovesNebulizer TubiriK/Faccmiisk

£»*••& Uf, dj-t-f/i.j-' 'I Jtf* ,«T,.*r-*? j^-fc^'^^'"''^' X" /•£•*-,

M /& fits- • 7'

Signature Follow Up

Foe

Well Child Examillatiott (Birth lo 6 Years of Age)

Name' DOB Age

, \ Hearing. Standard Pass / Fail Vision VEP . 'Pass /FailEroscan /fassj l-ail MB Pass /Pail

for Failures) "litmus fass /TailCBC/Lead Script (_ |

(See Attached forAbnormal')

Lead Assessment [ |VKS provided

Ye? / No

Pertinent Medical/Surgical History No Change AHcrgics/^NKDX

in Family Medical or Sodul History No Change

Parental Concerns Raised None

As.sessmcnt/PIau

Physical Exunui

( i en era 1HeadKyesLiarsNoseMouth/ThroatNeckChest/BackCardiacPulmonaryAbdomenPelvisMuseuloskeletiilNeurologic.SKin

intionN A

r_ ."(N i \ tfv-wAf vv u v-

l ( //' ' ' Vi**..

Tanner:

Medications None

DevelopmentASQ Communication

Gross MotorFine MotorProblem SolvingPersoiial/Soeial

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

ASQ:SE |(circled viilue indicates out of range)Results Discussed:Patient referred:

Y'Y

NN

Mile.s-l.oiie ExpectationsSafetyDaycare/SehoolTmnuJiiizationsNutrition Current Food IntakeCoiuiseling Exercise

Diet PlaniiiuftRisk Kiictors

v;

Tfirgot weiglu goals (1)y dale).-Procedures:Liar Curetlagetiar Piercing:

GoldDiamond

Forms Filled out

Signature:' Follow Up:

p.D.,KA,A,P.M.D..F.A.A.P., M.D., KA.A.P.

PRACTICE LIMITED TO PEDIATRICS & ADOLESCENT MEDICINE

iif;M.D.,r.A.A,r," ..P.A.A.P.

tf.O., F.A.AP.iates

Date Name \Ni *r\ P*

Date of Birth

Birth and Delivery: NormalNeonatal Problems at Birth: No

CISYes:

Breech(\JO t

Birth Wt:Feeding: Breast

Discharge Wt:

Past Hospitalizations: NoneYes: __ ' {

Or Time

ISerious Illnesses: NoneYes:

Medications: None. Yes.

Age Health and/or Allergies

MotherFatherSiblingSiblingSibling

Family History

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

T.B. or T.B. contact; Yes NoDiabetes: Yes NoSeizures: Yes No ———

No

Other Significant Problems (patient or family)

Development

Sits

Stands .

Cruises

Walks _

Speech

Patient Name

Mother

Father

HiBDAct Hib DPcnlacal D

MMRX"Proquad D

Proquad n

Flu Vaccine

Flu Vaccine

DTDorTdnTdapnBoostrix I iAd ace I n

Synagis

Mantoux

Other

Inj D Mist D

In] I

cc

Mist a

MistD

InjD IV

Inj D IV

n Mistn

JD Misin

Inj D

InjD

2 to 20 Years: GirlsStature-for-age andWelght-for-age percentiles Nar.w Record*.

12 13 14 15 16 17 18 19 20Mother's Stature

Fathefs stature

AbbottNutrition

www.gbbottnutrition.com

Pcdialyte*Oral utacb

Pedicure'Complete, Balanced Nutrition*

Nuiritionaljy complete ,-iminoadcl-bassti mndical food and

nula wrtl"! ii'On

'SOURCfi: rievelopccl by llic

sUtistirs in collaboration witlithe National Currier for ChronicDisuasB Prevention and HualhPromotion (2000).

This chart Is Cuiisistant with C'DOgiuvvlh data as nf Novemljui 2007.

IKlp://www.cdc.g«v/growlllChart«

10 11 12 13 14 15 Ife 17 18 19 20

SUFFOLK COUNTY DEPARTMENT OF SOCIAL SERVICESCHILD PLACEMENT BUREAU

CHILD/ADOLESCENT ASSESSMENT FORM

Last Name r * -^ CaJaJLtx, First Name Lî o ,-\ a<^CIN Number Case NumberLast M.D. Visit Name

It

HEALTH HISTORYILLNESSES; M3ne_CURRENT HEATLH Gaoi-HOSPITALIZATIONS ôr.SURGERY N*n«_

ALLERGIES N><<-^HISTORY OF ASTHMA YesHASMEDS- NEBULIZER —

of M.D.

HEALTH STATUSSLEEPSLEEP PATTERN IS IHOURS PER NIGHTNIGHTMARES YES

NUTRITIONNO u-~ Appetite YK~~r- •

FOOD ALLERGIES

DOB ~7-C~oS' Date 9 l±+lo<jDale of Placement ^//t /d^

Foster home ^^^4,5^,0

•JORMAL FOR AGEty^

NO <x-

MCAPEAK FLOW

INTERACTIONS: yu-l~j&t~*-£' L^-^J-H— VD /~ /*• rb>-fifu-^ f- •TÔj^Cflo-^.'

PHYSICAL ASSESSMENTSYSTEM/AREAASSESSED

WNL Assessment/PertinentHistory

SYSTEM/AREAASSESSED

WNL Assessment/PertinentHistory

Eyes/Ears

Mouth/Nose

Throat

GI

Nutritional Status

Cardiovascular G.U.

Reproductive

Respiratory Musculo/Skeletal

Skull Circ.Endocrine

NeuroI/

Skin

i~

1r I'^D

Temperature ~-Zi 31 ,2>=* 7&J PulseRespiration Blood Pressure

TERMS: WNL=Within Nomial Limits; GI=GastrointestinaI; GU=Genito-urinary; DDST II Score=Denver DevelopmentalSystems Test

PSYCHOLOGICALBEHAVIORAL/ACADEMIC PROBLEMSHISTORY OF VIOLENT BEHAVIOR QSUICIDAL THOUGHTS CD V 0^SIGNS / SYMPTOMS OF DEPRESSION Q YCURRENT GRADE AT SCHOOL

DEVELOPMENTAL ASSESSMENT ,_AGE AT ASSESSMENT ty'tjr* JWKUEHEIGHT H ji . *' WEIGHT S 3 • j^DDST II* SCORE [ IF UNDER 6 YEARS] NORMAL Q SUSPECT Q ABNORMALQ^

PERSONAL/SOCIAL AGE APPROPRIATE R" FINE MOTOR AGE APPROPRIATE QGROSS MOTOR AGE APPROPRIATE ET LANGUAGE AGE APPROPRIATED

TEACHINGNEED FOR HEARING/ VISION SCREENINGUSE OF SEAT BELT [ABOVE 70Ibs] / BOOSTER SEAT [ 40-601bs] /CAR SEAT 0Y QNTHERE IS A THERMOMETER IN THE HOME 0Y QNTHE NEED FORDENTAL CARE WAS STRESSED BY DNIMMUNIZATIONSUPTODATEFORAGE DY DN>LEAD SCREENING AT I AND 2 YEARS DY

ADDITIONAL FINDINGS

u

~fa

BM/ --^^ . 9'?'^ p^câu^,

MEDICATIONS

SIGNATURE

TERMS: WNL=Wilhin Normal Limits; GI=GastrointestinaI; GU=Genito-urinary; DDST II Score=DenvtrDevelopmental Systems Test

NEW YORK STATE DEPARTMENT OF HEALTH Informed CoOSBnt

AIDS institute to Perform HIV Testing

My health care provider has answered any questions I have regardingHIV testing and has given me written information with the followingdetails about HIV testing:

• HIV is the virus that causes AIDS.

• The only way to know if you have HIV is to be tested.

• HIV testing is important for your health, especially for pregnant women.

• HIV testing is voluntary. Consent can be withdrawn at any time.

• Several testing options are available, including anonymous and confidential.

• State law protects the confidentiality of test results and also protects test subjectsfrom discrimination based on HIV status.

• My health care provider will talk with me about notifying my sex orneedle-sharing partners of possible exposure, if I test positive.

I agree to testing for the diagnosis of HIV infection. If I am found to have HIV, I agree toadditional testing which may occur on the sample I provide today to determine the besttreatment for me and to help guide HIV prevention programs. I also agree to future teststo guide my treatment. I understand that I can withdraw my consent for future tests atanytime.

For pregnant women only:In addition to the testing described above, I authorize my health care provider torepeat HIV diagnostic testing later in this pregnancy. I understand that my healthcare provider will discuss this testing with me before the test is repeated and willprovide me with the test results. The consent to repeat diagnostic testing is limitedto the course of my current pregnancy and can be withdrawn at any time.

~*6~^~-=a. — . Date:(Test subject or legally authorized representative)

If legal representative, indicate relationship to subject:

Printed Name: A-e - uC. ,-, -S i Ft>r. L^"^^^ P,<> 'uJfctLJ, D°3 7~^ -o 5~

Medical Record #: _

Except for expedited HIV testing on labor units, this form replaces other HIV testing consent forms

as of June 1.2005.

NOTE; this form is intended to be used in conjunction with DOH-2556J. Part A. _

DOH-2556(5/05)

IPAA Compliant Authorization for P ' e of Medical InformationNew York state Department of Health - and Confidenxi.il HIV* Related Information

This form authorizes release of medical information including HIV-related information. You may choose to release just your non-HIV medicalinformation, just your HIV-related information, or both. Your information may be protected from disclosure by federal privacy law and state law.Confidential HIV-related information is any information indicating that a person has had an HIV-related test or has HIV infection, HIV-relatedillness or AIDS, or any information that could indicate a person has been potentially exposed to HIV.

Under New York State Law HIV-related information can only be given to people you allow to have it by signing a written release. This informationmay also be released to the following: health providers caring for you or your exposed child; health officials when required by law; insurers topermit payment; persons involved in foster care or adoption; official correctional, probation and parole staff; emergency or health care staff whoare accidentally exposed to your blood, or by special court order. Under State law, anyone who illegally discloses HIV-related information may bepunished by a fine of up to $5,000 and a jail term of up to one year. However, some re-disclosures of medical and/or HIV-related information arenot protected under federal law. For more information about HIV confidentiality, call the New York State Department of Health HIV ConfidentialityHotline at 1-800-962-5065; for information regarding federal privacy protection, call the Office for Civil Rights at 1-800-368-1019.

By checking the boxes below and signing this form, medical information and/or HIV-related information can be given to the people listed onpage two (or additional sheets if necessary) of the form, for the reason(s) listed. Upon your request, the facility or person disclosing your medicalinformation must provide you with a copy of this form.

I consent to disclosure of (please check all that apply): ff] My HIV-retated information

| | Both (non-HIV medical and HIV-related information)

| | My non-HIV medical information **

Information in the box below must be completed.

Name and address of facility/person disclosing HIV-related and/or medical information:

Name of person whose information will be released: l/^< ^ of\ e*^ p / S Cft-Tex. i I

Name and address of person signing this form (if other than above):

Relationship to person whose information will be released:

Describe information to be released; HIV Test Results

Reason for release of information: To conform with MmiJiistrative Directive 95-AEM-15.

Time Period During Which Release of Information is Authorized From: *9 / o * ? To:

Disclosures cannot be revoked, once authorized. Additional exceptions to the right to revoke consent if any:

Description of the consequences, if any, of failing to consent to disclosure upon treatment payment enrollment or eligiblity for benefits(Note: Federal privacy regulations may restrict some consequences):

None

All facilities/persons listed on pages 1,2 (and 3 if used) of this form may share information among and between themselves for the purpose ofproviding medical care and services. Please sign below to authorize.

Signature --^—^-*^ — «- - o - < ^ — - _ _ Date

'Human Immunodeficiency Virus that causes AIDS** If releasing only non-HIV medical information, you may use this form or another HlPAA-compliant general medical release form.

DOH-2557 (5/os) p i of 3 Please Complete Information on Page 2.

<IPAA Compliant Authorization forr ,e of Medical Information

and Confidential HIV* Related Information

Complete information for each facility/person to be given general medical information and/or HIV-related information.Attach additional sheets as necessary. It is recommended that blank lines be crossed out prior to signing.

Name and address of facility/person to be given general medical and/or HIV-related information:

Geraldine Sass, R.N. - Suffolk County Department of Social ServicesFamily & Children's Services Division (Macftrtfaur Building - 3rd Floor)P.O. Box 18100

Hauppauge, New York 11788Reason for release, if other than stated on page 1:

If information to be disclosed to this facility/person is limited, please specify:

Name and address of facility/person to be given general medical and/or HIV-related information:

Reason for release, if other than stated on page 1:

If information to be disclosed to this facility/person is limited, please specify:

The law protects you from HIV related discrimination in housing, employment, health care and other services. For more information call theNew York State Division of Human Rights Office of AIDS Discrimination Issues at 1-800-523-2437 or (212) 480-2493 or the New York CityCommission of Human Rights at (212) 306-5070. These agencies are responsible for protecting your rights.

My questions about this form have been answered. I know that I do not have to allow release of my medical and/or HIV-relatedinformation, and that I can change my mind at any time and revoke my authorization by writing the facility/person obtaining this release. Iauthorize the facility/person noted on page one to release medical and/or HIV-related information of the person named on page one to theorganizations/persons listed.

Signature ^•~ê-—^-^-A- " • • —>fr-g-~—- Date / / =(Subject of information or legally authorized representative)

/•If legal representative, indicate relationship to subject:

Print Name

Client/Patient Number

DOH-2557(5/05)p2of3

01/26/2010 TUB 14:50 FAX 16318549 00 SOCIAL SERVICES C P B

*** TX REPORT ***

TRANSMISSION OK

TX/RX NO 1783CONNECTION TEL 92812118CONNECTION IDST. TIME 01/26 14:49USAGE T 00'50PCS. SENT 2RESULT OK

COUNTY OF SUFFOLK

STEVE LEVYSUFFOLK COUNTY EXECUTIVE

DEPARTMENT OF SOCIAL SERVICES Gregory BlassCOMMISSIONER

FAX TRANSMITTAL COVER SHEET

Date: V

From;

\Number of pages, including this cover sheet D \

CX <v _

Fax Number sent to: Qax ^-r\ \ D&te: Time:

CONFIDENTIALITY NOTICE

The documents which accomoanv this telefax transmission sheet contain

Authorization fo. Release of Protected Health In. /matron (PHI)

Address:\ nsb

I hereby anthoriie the me and/or disclosure of my protected health information as ecriM Below. Iundentead that this authorization hi 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/orprojram discloshjg information)

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

Chfld Protective Services TEAM#\~1P.O. Box 18100Hauppaute. New York 11788-8900

Information to be released: (Check app gories)Treatment planDates of treatmentPsychological/Psychiatric evaluation

Laboratory A X-ray reports/resultsMedical history

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

I understand that the above information is protected by Federal Regulations 42 CFR, Part 2, "Confidentiality ofAlcohol and Drag Abase Patient Records" and cannot be disclosed witirant my consent unless otherwise providedfor in the regulations. I understand that I may revoke thb anthorizatioa at any tiiiie by notifying the providingorganizatioa in writing, bat if I do it woB't have any effect OB any actioa they took before they received therevocation. I understand that tab permission will expire when acted upoa, or ninety (90) days from Otis date,whichever conies 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 Name: VpT \

Date;

Relationship to Individual:

Yon are entitled to a copy of this authorization after yon sign HRelease of Information-Alcohol and Drug Abuse Patient Records-Revised (5/04)

03/31/05

01/26/2010 TUB 16:01 FAX 16318549300 SOCIAL SERVICES C P B

*** TX REPORT ***

TRANSMISSION OK


COUNTY OF SUFFOLK


DEPARTMENT OF SOCIAL SERVICES Gregory Bias*COMMISSIONER


Number of pages, including this cover sheet-

Fax Number sent to: £ \U. -T"l°iL0-\2"/ftD*te: 'me:


The documents which accompany this telefax transmission sheet contain

Support for Ms. Palmiotti

Housing, Food, Cigarettes, etc. Ail expenses for living at home, food shopping. Use of the internet, cable

tv, washing machine, dryer, car, air conditioner, heat, coffee, milk, driving to doctors appointments, helpfill out forms for hospitals, clinics, food stamps, WIC, Medicaid. Support and follow up for her issues withher work, and help with her personal issues. Paid over $3,000 to fix her tractor trailer, follow up with herlicense suspension. Fixing her vehicle. I Also purchased a 1996 Ford Windstar minivan to have a secondvehicle for Ms. Palmiotti to use as needed, which she refused to use.

Support for Winona (Babv)

Housing, Food, Care, etc.

Purchased Winona a Stroller, Pack 'n Play (Play Pen), Car Seat, Baby Carrier, Crib, Mattress, BeddingDiapers, Baby Wipes, Formula, Baby food, (Jars, Rice Cereal), Clothes, Air Conditioner, Some BabyBottles, (other basic necessities) Prescriptions, Breast Pump, Thermometer, bibs, wash clothes, babyspoons, pacifiers, toys, Gold Heart Locket/Chain for Christmas.

Abuse incurred from Ms. Palmiotti.

Physical, mental, and much verbal and emotional abuse towards me daily. Verbal, Physical abusetowards my mother. Verbal abuse towards my sister. Unfaithful, always refused a paternity test, verydemanding and controlling (her way, or no way! She's right, I'm always wrong) Yelling, Slamming doors,Continuing harassment, threatening, throwing/breaking household items, hiding my car keys, cellphone, shutting off computers and phones at circuit breaker, scratching, damage to my vehicle.

Ms. Palmiotti slept while I was at work and kept me up at night so I can't sleep. If I picked up mydaughter, she would tell me to put her down, that she's not mine. If I did not pick up my daughter shewould accuse me of being a bad father. I cannot bring my daughter anywhere. Ms. Palmiotti was alwayspresent, and I was never left alone with my daughter. My daughter cannot have any contact with any ofmy family members, but Ms. Palmiotti would leave her with strangers such as her co-workers (Truck

Drivers with prior arrests and drug problems)

Much physical abuse, recent abuse included an incident in 2005, when I was in the bathroom on thecommode and she enters the bathroom and starts pulling and twisting my breasts and chest hair veryhard, that incurred bruising, and a week or so after, she stepped on my foot and bruised my toe nail thatas of today has not healed correctly, and a few attempts to hit me at my groin area. Other physicalabuse was an incident in 2003, which she hit me in the forehead with a small barbecue propane tank.Other physical abuse was a lot of spitting in my face, and a big domestic violence issue in 1999, where

she was arrested and charged with a Class C Felony for hitting me repeatedly over the head with a 2x4

piece of wood, and stabbed me in the face with my car keys. Again in 2000 she was arrested for criminal

mischief for damaging my surveillance camera by pulling on the wire, and the rain gutter fell on my

vehicle and damaged the hood. Total damages about $1,800.

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PayFal - Receipt Page 1 of I

Receipt

Ship To: Paul Plsctelli Seller Information: burkman333318 Ellison Ave [email protected], NY 11590United States

Transaction ZD: 66161551PK893091M Placed on Oct. 24, 2005

Item 9

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Baby Bellini Whitewashed Woe ' '"Mb Page 1 of 2

new york craigslist > long island > baby & kid stuff > Baby Bellini Whitewashed Wood Criblast modified: Sun, IS Oct 09:44 EOT

Avoid fi:am§ j|_ jrsid by dealing locally: (report scam attempts to [email protected])• non-local deals involving shipping, wire transfer, cashier checks, escrow, or 3rd party payments areusually fraudulent• there are no such things as "craigslist payment system", "craigslist buyer protection", or "craigslistseller certification"

please flag with care: [mtecategorteed] [prohibited] [spam] [discussion] [best of]

email this posting to a friend

Baby Bellini Whitewashed Wood Crib - $185

Reply to: [email protected]: 2006-10-15,9:44AM EDT

I have a beautiful Baby Bellini "annie" style crib that comes with the mattress. It is natural wood that hasa slight white tint to it. It converts to a toddle bed and has a draw under the crib for storage. TheMattress has 3 levels so its great from a small baby all the way up to a toddler. The crib was purchasedfor 700.00 plus the mattress and is in excellent condition. It is the same model still out in the BabyBellini stores. Any questions please contact me. Thank you

this is in or around Garden Cityno — it's NOT ok to contact this poster with services or other commercial interests

220868002

Copyright © 2006 craigslist, inc. terms of use privacy policy feedback forum

http://newyork.craigslist.org/lgi/bab/220868002.html 10/16/2006

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1 SCANNED PHARMACY 1.10RX# 503857

1 KELLY CLUB DOLL ASST 10.29 T

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WTNQ12 ** CASE INVOLVEMENT FOR CIN: BV16784F ** Date 01/15/2010 Page 1 of 1Name PALMIOTTI WINONA M Sex F SSN 067-70-3251 DOB 04/07/1973

FOR CASE INQUIRY: (Choose 1, 2 or 3) * Selection " *Case - Num Case-Typ Case--Stat Ind-Stat Case NameAuthorization-Period Auth - Num Eff-Date Street Address

Act-Date City St ZipLst-Stat Telephone El

1)

2)

OfficeDist

S0090089809/16/09 --110SUFF

POOD1554708/26/09 --BSUFF

UnitWorker

SERV03/16/10017108

SN-CSH10/24/09110501129

Pend-MAEPend-FS/

ACTIVE13706642

CLOSED13666430

ACT PALMIOTTI WINONA218 COUL ST.

09/16/09 MANSFIELD OH 44902

CAS-CL10/25/0908/26/09ACT

PALMIOTTI WINONA3085 VETS HWYRONKONKOMA NY 11779

3) FOOD15547 NPA-FS ACTIVE ACT11/01/09 -- 05/31/10 13604386 11/01/09B 12070 _ 11/01/09SUFF 1367 CAS-CL

PALMIOTTI WINONA3085 VETS HWYRONKONKOMA NY 11779

SEARCH COMPLETED

Police Request Tracking System - Incident Request

J Log ID Request Date14753 j 1/7/2010 4:43:01PM

Supervisor NameSally O'donnell j

Team / Worker ID Team Fax

Priority Cancel Reason| (1. Priority None

Supervisor Phone Supervisor E-mail631-854-9130 j Satly.O'donnelKgdf

Offense| (Check All

a.state.ny.us

Processed Date Completed SCPD Return Type

j 17 1 | 108 j [631-854-9347 j |None j 'NO

CPS Comments

grandparents have petioned for custody of fosterchiid

* First Name Last name J DobPhillip Marzocco 01/22/1945

Address Address 2 , Cit*24 Femdale Boulevard (slip

Total Addresses : 1

Alias For Individual: NoneTotal Aliases : 0

First Name Last name NJ*~£As. DobCarol Marzocco "^ 08/27/1947

Address Address 2 City24 Ferndale Boulevard (slip

Total Addresses : 1

Alias For individual: NoneTotal Aliases : G

| (None

SCPD Comments

Court Date1/20/2010 |

Division[ FCSA |

S

I

II

SPP Results SCPD - addl Addr SCPD - add! Alias

Not Found j iNo | No J

None

PMPJM>fl»"fo

state zip,NY 11751

Dup/Loatefo

state zip.NY 11751

* — - * — •"»

SOUNDEX &PRIOR ARRESTS

NEGATIVE

FAXED ( E-MAILED^PUPHONED ep*a| /"Message

DATE iiSUO— \

1/8/2010 11.09.29AM InckfentRequestReixxtrpI Page 1 of 2

COUNTY OF SUFFOLK


DEPARTMENT OF SOCIAL SERVICES GREGORY J. BLASSCOMMISSIONER

/? 1(JÂt-Z- sA-^-^*\J*<s4^> _ give permission for the Department of Social Services

0

to conduct Soundex clearances with the Suffolk County Police Department. In addition, I give permission to

conduct SCR clearances.

Name:

Date of Birth:

Address:

Signature ' Date

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

COUNTY OF SUFFOLK



give permission for the Department of Social Services

to conduct Soundex clearances with the Suffolk County Police Department. In addition, I give permission to

conduct SCR clearances.

XTName:

Date of Birth:

Address:

Dat/

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

Case Name: Winona PalmiottiCase Number: S00900898Court Ordered: Yes Kl No Q

TRANSPORTATION SERVICESREQUISITION/RECORD

Requisition Date: 12/29/09Child/Children and DOB: Winona Piscitelli

Type of Activity: ^ Supervised Visit with transportation[~1 Supervised Visit without transportation[~] Transportation Only

I Deliver items[ Drop off records

Visit or Activity to Commence on: Friday 1/15/10Frequency of Visit: ^]l time Qweekly Obi-weekly QmonthlyLength of Visit: 1.5 hoursTime of visit: (check) [/3am CHafternoon Oevening dJSaturday(IF VISIT MUST BE A SPECIFIC TIME OR DAY, PLEASE INDICATE):

Foster Parent or Custodian:AddresHome Phone:

Person(s) Authorized to have visit and relationship to children: Mother Winona PalmiottiHome Phone: 516-238-0371 Cell:

PICK UP location(s) (list all):l

Visitation Site/Address: dss

RETURN location(s): daycare

Please check all that apply:QOrder of Protection (Attach copy)dLetter from custodian giving permission for DSS to transport (Attach copy)Qlndividuals not permitted at visit:

MEDICAL INFORMATION (check all that apply, please note individual with condition/allergy):QAllergy (list allergy) dAsthmaQSeizure disorder C]OtherQSpecial equipment

Comments: One time visit for maternal grandfather and step grandmother, child has never met them

Caseworker: Lori Towns Team#17 /Extension:

Assigned to: \LJ^^V\\ jNg_- Start/Date: \ 1 )\0 Tim\:\QU^Qj±^ \

Transportation Unit cannot handle request at this ti

Transportation Coordinator Date

12/28/2009 12:02 FAX 6318549347

TRANSMISSION OK

TX/RX NOCONNECTION TELSUBADDRESSCONNECTION IDST. TIMEUSAGE TPCS. SENTRESULT

SC CPB IfiOOl

*** TX REPORT# *#«*$*««# **«#«*

095599208468

12/28 11:5902 '4616

OK

COUNTY OF SUFFOLK

LEVYSUFFOLK COUNTY EXECUTIVE

DEPARTMENT OF SOCIAL SERVICES Gregory BlMsCOMMISSIONER


From:

To:

Ntmber of pages, including this cover sheet: \ r

Faw Number sent to: n / . . .. Date: Time:


The documents which accompany this telefax transmission sheet containinformation which is confidential and/or legally privileged, and which is intendedONLY for the use of the person or entity named above. If you have received thistransmission in error you are hereby notified that any disclosure, copying,

.OUNTY OF SUFFOLK



December 28, 2009

Pederson Krag11 Route 111Smithtown,NY11787

RE: Winona M. Palmiotti (DOB 4/7/73)

To Whom It May Concern:

The above named person is currently receiving services from Suffolk County Department of Social Services.This agency is requesting that you please schedule Ms. Palmiotti for a mental health evaluation as soon aspossible. Ms. Palmiotti does not have medical insurance. Please work with Ms. Palmiotti on a sliding scale foryour fee for services. Ms. Palmiotti's next Suffolk County Family Court date is January 21, 2010. Ms.Palmiotti's daughter, Winona Piscitelli (DOB 7/6/05) is currently in foster care. I have enclosed the NeglectPetition and current court order. Please review these two for a history of the case.

Please feel free to contact me at 631 -854-9397 with any questions.

Lori Towns, CaseworkerChild Placement Bureau, Team 17

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

12/28/2009 MON 09:51 FAX 16318549300 SOCIAL SERVICES C P B

*****#*************#*** TX REPORT ************************

TRANSMISSION OK


COUNTY OF SUFFOLK


DEPARTMENT OF SOCIAL SERVICES Gregory BlassCOMMISSIONER


Date:

From:

Number of pages, including this cover sheet: .

Fax Number sent to:q^/vv_cjyjr ^ Date: Time:


The documents which accompany this telefax transmission sheet contain

Case Name: Winona PaimiottiCase Number: S00900898Court Ordered: Yes No Q

TRANSPORTATION SERVICESREQUISITION/RECORD

Requisition Date: 12/17/09Child/Children and DOB: Winona Piscitelli

Type of Activity: [>3 Supervised Visit with transportation[~| Supervised Visit without transportationD Transportation Only

CH Deliver itemsl~1 Drop off records

Visit or Activity to Commence on: Week of 12/28Frequency of Visit: 131 time [^weekly Qbi-weekly l~1monthlyLength of Visit: 2 hoursTime of visit: (check) Dam Oafternoon Devening f~]Saturday(IF VISIT MUST BE A SPECIFIC TIME OR DAY, PLEASE INDICATE):

Foster Parent or Custodian:*Address:Home Phone: i Cell?

Person(s) Authorized to have visit and relationship to children: Mother Winona PaimiottiHome Phone: 516-238-0371 Cell:

PICK UP location(s) (list all)

Visitation Site/Address: dss

RETURN location(s)t|

Please check all that apply:QOrder of Protection (Attach copy)

DEC 1 7 2009

LjLetter from custodian giving permission for DSS to transport (Attach copy)[Îndividuals not permitted at visit:

8Child Placement Bureau

Sunb!k County Sods! Ssrvices

MEDICAL INFORMATION (check all that apply, please note individual with condition/allergy):IZlAIlergy (list allergy) OAsthmaDSeizure disorder DotherQSpecial equipment DNone

, \~|J i \ f ^

Comments: One time make up visit for any day /anytime this week. CSW Josephine is off. Normal visit is Wed 1:30-3:30, However a morning visit is also good for allMother is severly mentally ill. CSW must watch and listen very closely

aseworker: Lori Towns Team# 17 Extension: 4-9397

Assigned to: V1 Clp <UA C-^P x; 'fO' Start Date: IO|3b|cO Time: /^

Transportation Unit cannot handle request at this time: Q. QCn.

Transportation Coordinator Date

COUNTY OF SUFFOLK


DEPARTMENT OF SOCIAL SERVICES JANET DEMARZOCOMMISSIONER

PERMISSION FOR RELEASE OF INFORMATION

fYI hereby authorize

at and

Suffolk County Dept. of Social Services at 3455 Veterans Highway, NY 1 1 779to communicate and release information to each other regarding:

V\

CLkJL

I understand that the information to be released is confidential ana protectedfrom disclosure.

I understand that I have the right to cancel this Permission for Release of Information atanytime before it is released.

I also understand that this Permission for Release of Information will expire when actedupon, or six months, whichever comes first.

Relationship: *T&\ j

Address:

Etete

BOX 181OO HAUPPAUGE, N.Y. 1I788-B9OO (631)854-9935

SAMARITAN\- HOSPITAL MEDICAL CENTER

Member of Catholic Health Services of Long Island

WHEN CAKING MATTERSA MAGNET" DESIGNATED HOSPtTAl

(631) 376-4444 • www.good-sanuritan-hospial.otg

Nursing's Highest Honor

December 17,2009

To Whom it May Concern;

This is to verify that Winona Palmiotti has attended the S.T.E.P. Parenting series(Systematic Training for Effective Parenting) at Good Samaritan Hospital MedicalCenter. This four week series focuses on issues relating to parenting children ages birththrough five and includes the following topics: communicating with your child, instillingself-esteem, positive discipline techniques, nurturing social and emotional developmentand fostering cooperation.

The dates were as follows:Thursday, November 19, 2009

Thursday, December 3, 2009



If you have any questions or require additional information, please feel free to contact meat (631)376-4159.

Sincerely,

•7X /£**•»*—• ^}£^r*~<->/ S '

Karen Kaplan, MS, RNPerinatal Education Coordinator

SAMARITAN; HOSPITAL MEDICAL CENTER

A Member of Catholic Health Services of Long Island

WHEN CARING MATTERSA MAGNET-DESIGNATED HOSPITAt

(631) 376-4444 • www.good-samaritan-hoapital.otg


November 19, 2009


This is to verify that Winona Palmiotti is attending the S.T.E.P. Parenting series(Systematic Training for Effective Parenting) at Good Samaritan Hospital MedicalCenter. This four week series focuses on issues relating to parenting children ages birththrough five and includes the following topics: communicating with your child, instillingself-esteem, positive discipline techniques, nurturing social and emotional developmentand fostering cooperation.

The dates of the series are as follows:

Thursday, November 19, 2009





Sincerely,


AMARITANIS HOSPITAL MEDICAL CENTER

A Member of Catholic Health Sendees of Long Island

WHEIV CARING MATTERSA MAGNET-DESIGNATED HOSHTAl

(631) 376-4444 • www.good-sama-itan-hoSpitjI.org


, . .October 30, 2009


This is to verify that Winona Palmiotti is registered for the S.T.E.P. Parenting series(Systematic Training for Effective Parenting) at Good, Samaritan Hospital MedicalCenter. This five week series focuses on issues relating to parenting children ages birththrough five and includes the following topics:, communicating with your child, instillingself-esteem, positive discipline techniques, nurturing social and emotional developmentand fostering cooperation.

The dates of the next series are as follows: ; ; , ; • ;

Thursday, November 12, 2009

Thursday, November 19, 2009! ' ( :'i • : . * ' . ' ' :





Sincerely,


I, VI \(NQQ>^\\T^yf^6nJ\V hereby acknowledge that on \2.l<\/ 0^ » mY caseworkeran 'and I discussed the need for me to participate in:

I I PsychotherapyDrug RehabilitationAlcohol RehabilitationParent TrainingOther (specif

I understand that my participation in the above satisfied the conditions of my:

n Court OrderI Voluntary Placement Agreement

^BxJUniform Case Record Plan

I have been given the following resources:

cfr V\e^r^ WolftKcfr ûe^r^.

\

I understand that failure to follow the above stipulations constitutes failure to plan for mychild and could be basis for Family Court proceeding to terminate my parental rights.

Parent Signature

Caseworker Si

Date

PLACEMENT OF YOUR CHILD IN FOSTER CARE MAY RESULT IN THE LOSS OF YOUR RIGHTS TO YOUR CHILD. IFYOUR CHILD STAYS IN FOSTER CARE FOR IS OF THE MCST RECENT 22 MONTHS. THE AGENCY MAY BE REOUIREDBY LAW TO FILE A PETITION TO TERMINATE YOUR PARENTAL RIGHTS AND MAY FILE BEFORE THE END OF THE15 MONTH PERIOD.

MENTAL HEALTH CLINICS

Brentwood Mental Health Center 853-7300J841 Brentwood Road, Brentwood, NY11717

Brookhaven MHC :Access Center 447-3048

Shirley Center 852-1070550 Montauk Highway, Shirley, NY, 11967 Mon-Wed 9-8PM

Thurs.-Fri. 9-5PM

Patchogue Center 854-1222365 E. Main Street, Patchogue, NY11772

Buckman Center - Brentwood 761-2289Pilgrim Psych Center, Bldg 47998 Crooked Hill Road, W. Brentwood, NY 11717

Catholic Charities:

Bay Shore Center 665-67079 Fourth Avenue, Bay Shore, NY 11706

Medford Center 654-19191727 North Ocean Avenue, Medford, NY 11763

Children and Family Mental Health Services:

East 598-4726221 Broadway - Suite. 205, Amityville, NY 11701

West 264-432537 John Street, Amityville, NY, 11701

School Based Program 264-432537 John Steel, Amityville, NY, 11701

Wyandanch 253-03761449 Straight Path, Wyandanch, NY, 11798

13

Documents

A CHILD 5