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MENTAL HEALTH CLINICS (cont)

Family Counseling Service: Shirley 464-10 William Floyd Parkway, Shirley, NY, 11967 Hampton Bays 154-5 Montauk Highway, Hampton Bays, NY, 11946 399-9217

728-7232

Farmingville Mental Health Center.. 15 Horseblock PL Farmingville, NY, 11738 Family Service League: East Hampton Center 66 Newtown Lane, East Hampton, NY, 11937 Hampton Bays Center 225 West Montauk Highway, Suite 4, Hampton Bays, NY, 11946 Mattituck Center 755 Main Road, Mattituck, NY, 11952 Family Wellness Center (FREE) 120 Plant Avenue, Hauppauge, NY, 11788

854-2552

324-3344

723-2316

298-8642

851-3810

PEGS Mental Health Centers: Long Island Call Center Center Moriches Center 220 Main Street, Center Moriches, NY, 11934 Central Islip 115 Carleton Avenue, Central Islip, NY, 11722 Madonna Heights Services 151 Burrs Lane, Dix Hills, NY, 11746

1-(516) 364-0794 874-2700

234-7807

643-8800

14

JUST KIDS
Early Childhood Learning Center
: hereby give consent to have my child, W j1 fjDfifl. rI^>U *Q ^ <valuated by Just Kids in the following area(s) and with the 1ollowing measures: ,
Steve H.:ld Executive D ireetor Sreplten Cordon Director Cathy Cianfirano Director ol Chi|dn.-n's Services

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 Scale Oral Motor Eating Evaluation (Morris) Oral-Peripheral Examination an'juage Sample Fruiting's Stages for Acquisition of Pragmatics ) Wesi:by Symbolic Play Scale ) Stuttering Prediction Instrument (SPI)

Audiolcgical I have been informed about the purpose of the evaluation and tie. methods to be used. I have received my Due Process Rj g-hts.

Date
Middle Island P.O. Box 12, longw ood Road Vliddte bland, NY LI 953 631) 924-0008 Phone 631) 924-1243 Fax ,indcnhurst ;87 Keljum Stree-

.indenhurst, NY
1757 531) 884-3000 Phone 531) 884-1959 Fax

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

jvcrhcad 40 East Main Street iverhead, NY H'901 131} 3694927 Phone 131) 369-1957 Fa:.: Illiaffl Floyd 1 Lexington Road urley, NY 11967 31)281-6300 Phone 31) 281-6096 Fax

Paient Signature (cisp)

Early Childhood Learning Center


I hereby give consent to have my child, W I Y\ DV\* f1<^1 TCI If valu evaluated by Just Kids in the following area(s) and with the ollo 4 following- measures;
Stive Hd<t Executive kqpbtn Gor&tt Dinatu
Cadty Director of Children1!; Service*

( ./; Psychological Evaluation:

( ) Bayley

J
(

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 and zhe methods to be used. I have received my Due Process lights,

Middle Island Long wood F.oad P.O. Box 12 Middle Island, NY

11953
(631) 924-OClOg Phone

(631)924-1243 Fu*
Luideohurst

Date

88? KeUvuti Street Uodcnhurst, NY 11757 (631) 884-3000 Phone (631) 864-1959 Fax
Riverhead 555 East Mam Street Riverhead, NY 11901 (631) 369-1927 Phoria (631) 369-1957 Fax William Floyd

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

Parent Signature c fpsyed

Date

99 Laxingtor; Road
Shirley, NY 11967 (fi31)2Bl-6BCOPhonf.' (631) 281-6096 Fa>:

Cenfter
g I hereby give consent to have my child, e\ aluated by Just Kids in the following area(s) and ^with the f o l l o w i n g measures-. Occupational Therapy Evaluation
.Stephen Gordon Dirccrol tci:or o/ Children's .scrvicr?

u
Held

,-, ' ,-., \ , ;*! ' X''

( ) 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 Integration ( } BruninXs-Oseretsky Test of Motor Proficiency ( ) other

) Physical Therapy Evaluation


Michigan Early Intervention Developmental Profile (EIDP) Early Learning Accomplishment Profile 1ELAP) Learning Accomplishment Profile (LAP) Peabody Developmental Motor Scales (PDMS-2) Pediaciric Evaluation of Disability Inventory (PEDI) Other

.{''! ._-. ' ( ) -tfy( } \" ( ) t, .,,','' ' ( ) \ S * H .'". ( ) \^ . .

%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

Idle Island Box 12,

.die Wand, NY
i3

) 924-0008 Phone: ) 924-1243 Fax enhurst KeOum Street ifrihurst, NY 7 i 884-3000 Phone SS1.-1.9S9 Fax -head ; .ast Main Street bead, TvA'1 11901 369-1927 Phone 369-1957 Fax mi Floyd xington Road y, NY 11967 281-SSOoPlione 281-6096 Fax

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

Date

1 do not consent to the above.

aluation(s) requested

Parent Signature (cfp lot.03

Date

-.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 Associates PRACTICE LIMITED TO PEDIATRICS & ADOLESCENT MEDICINE

DATfirJOllLCB

NUMBER OF PAGES INCLUDING 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. IF YOU HAVE KRCEIVEU THIS TRAMSMTTTAL IN ERROR, PLEASE NOTIFY US LVTMEI5IATELY BY m,EPHONE, AND RETURN THJ5 MISDIRECTED TRANSMTiTAL TO US BY FAX OR MAIL AT THE NUMBRR ABOVE.

Pa.tieiit Name

JUJ n&

Pulsc

Oi Sat

Chief Com pla

Pertinent IVfccl/Surg History

None

family/Social lli-itory No Changes Day care Ye.s/No Smoke l:xposiu-c Yes / N o


Othei;;

Review oi ,>yst-CJtlN N HFENT Kesp Cardici GI Orlho Neuro Psych feeding Sleep/fatigue Weight Change Fevers

' t

<*^"SZs

'" "

--

\ v / \ / \/

V^ V T ^.' , 1. OOMM '/H


'///I
//Cf

\ / 1- ^

ImmuuiziitioHS Up To Date Allergies (^L^> McdUations N me

"" """

'

Yes / No

^'"

A
fT.-UM I'J '
>! / \t"^\l\~T -..,

^A/^ >_yL.c> 7<^^ r

V f" C" Procedures

Ean'rriation
Warl Removal Fhiorcsceia Eye Exam Tympanomelry HearinK Test Vision TestiriK Uriue Catheleri7,ation Spirornetjy Labs Dextrose Slick $*.- X! ^X- Heuic-occult '/r t\./-e-S-*-f <r<f-?,-/7/j**~-- Hemoglobin Rapid Strep Rapid Influenza Urine Culture

Physical F.vamin ation N ,A -^ General Head Eyes Ears 'Nose C/ Mouth/Throat / Neck LS Chest/Back .-'' Cardiac ^ Pulmonary Abdomen Pelvis Musculpskeleial Neuro log jo Skin Assessment/Plan

j #,4^.. (JL A *~

Nejj/Pos ] Neg / Pos Nefi / Pos Neg / Pos

Urine Analysis

Neg / Pos
4

(See attached, tor Positives) Urine R-I1CG 1 | Neg /Pos Nebulizer Treatments 1 2 3 Xopenex 0.3 0.63 1.25

Albuterol

1.25 2.5
1

Pulmicort .25 .5 Supplies Sterile Gloves Nebulizer TubiriK/Faccmiisk

*& Uf,
' 'I

dj-t-f/i.jJtf* ,T,.*r-*? j^-fc^'^^'"''^' X" /*-,

M /& fits-

'

Signature

Follow Up

Foe

Well Child Examillatiott (Birth lo 6 Years of Age)


Name'

DOB

Age

, \ Hearing.

Standard Eroscan

Pass / Fail Vision VEP . 'Pass /Fail / f a s s j l-ail MB Pass /Pail for Failures) "litmus fass /Tail CBC/Lead Script (_ |

(See Attached for Abnormal') Lead Assessment [ | VKS provided Ye? / No

Pertinent Medical/Surgical History

No Change

AHcrgics/^NKDX

Medications in Family Medical or Sodul History No Change

None

Parental Concerns Raised

None

Physical Exunui intion N A ( i en era 1 Head Kyes Liars Nose Mouth/Throat Neck Chest/Back Cardiac Pulmonary Abdomen Pelvis Museuloskeletiil Neurologic. SKin As.sessmcnt/PIau

Development Communication Gross Motor Fine Motor Problem Solving Persoiial/Soeial (circled values indicate out of range) Results Discussed: Y N Palicnt referred: Y N

ASQ

r
_

f vv u v-

."(N i \ tfv-wA

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

'' '

l(

Vi**..

//

Mile.s-l.oiie Expectations Safety

Tanner:

Daycare/Sehool
TmnuJiiizations Nutrition Current Food Intake Coiuiseling Exercise Diet Planiiiuft Risk Kiictors Tfirgot weiglu goals (1)y dale).Procedures: Liar Curetlage tiar Piercing: Gold Diamond Forms Filled out

v;

Signature:'

Follow Up:

p
Date

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

iif;M.D.,r.A.A,r, " ..P.A.A.P. tf.O., F.A.AP. iates

PRACTICE LIMITED TO PEDIATRICS & ADOLESCENT MEDICINE

Name

\Ni *r\

P* Date of Birth
Breech

Birth and Delivery: Normal Neonatal Problems at Birth: No Birth Wt: Feeding: Breast Past Hospitalizations: None Yes: __ '

CIS Yes:
Discharge Wt:

(\JO t

Or Time

{I

Serious Illnesses: None Yes: Medications: None.

Yes.

Age
Mother Father Sibling Sibling Sibling Family History
H( Disease, M.I. or Stroke before age of 50: Yes T.B. or T.B. contact; Yes No Diabetes: Yes No Seizures: Yes No Other Significant Problems (patient or family)

Health and/or Allergies

Development
No

Sits Stands . Cruises Walks _ Speech

Patient Name Mother Father

HiBD Act Hib D Pcnlacal D

MMRX" Proquad D

Proquad n

Inj D Mist D

Flu Vaccine
In] I

Mist a
MistD

InjD IV
Inj D IV

n Mistn JD Misin

Inj D

Flu Vaccine DTDorTdn Tdapn Boostrix I i Ad ace I n Synagis Mantoux Other

cc

InjD

2 to 20 Years: Girls Stature-for-age and Welght-for-age percentiles

Nar.w

Record*.

Mother's Stature Fathefs stature

12 13

14 15 16 17

18 19 20

Abbott

Nutrition
www.gbbottnutrition.com

Pcdialyte*
Oral utacb

Pedicure'
Complete, Balanced Nutrition*

Nuiritionaljy complete ,-imino adcl-bassti mndical food and nula wrtl"! ii'On

'SOURCfi: rievelopccl by llic

sUtistirs in collaboration witli the National Currier for Chronic DisuasB Prevention and Hualh Promotion (2000). This chart Is Cuiisistant with C'DO giuvvlh data as nf Novemljui 2007.
IKlp://www.cdc.gv/growlllChart

10 11 12 13 14 15 Ife 17 18 19 20

SUFFOLK COUNTY DEPARTMENT OF SOCIAL SERVICES CHILD PLACEMENT BUREAU CHILD/ADOLESCENT ASSESSMENT FORM Last Name r * -^ CaJaJLtx, First Name L^i ^ o ,-\ a<^ CIN Number Case Number Last M.D. Visit Name of M.D. DOB ~7-C~oS' Date 9 l+lo<j

Dale of Placement ^//t/d^ Foster home ^^^4,5^,0

It
HEALTH HISTORY
ILLNESSES; M3ne_ CURRENT HEATLH GaoiHOSPITALIZATIONS ^or.^ SURGERY N*n_ ALLERGIES N><<-^ HISTORY OF ASTHMA Yes H A S M E D S - NEBULIZER PEAK FLOW

HEALTH STATUS SLEEP


SLEEP PATTERN IS IJORMAL FOR AGEty^ HOURS PER NIGHT NIGHTMARES YES NO <x-

NO u-~
t~

NUTRITION Appetite YK~~r-


FOOD ALLERGIES

MCA

INTERACTIONS: yu-l~j&*-' L^-^J-H VD /~ /*

rb>-fifu-^

f- T^Oj^Cflo-^.'

PHYSICAL ASSESSMENT
SYSTEM/AREA ASSESSED Eyes/Ears Mouth/Nose
Nutritional Status

WNL

Assessment/Pertinent History

SYSTEM/AREA ASSESSED GI

WNL

Assessment/Pertinent History

Throat Cardiovascular

G.U.
Reproductive

Respiratory

Musculo/Skeletal

Endocrine

Skull Circ. Skin

i~

Neuro
I/
'^D 1r I

Temperature

~-Zi 31 ,2>=* 7&J

Respiration

Pulse Blood Pressure

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

PSYCHOLOGICAL
BEHAVIORAL/ACADEMIC PROBLEMS HISTORY OF VIOLENT BEHAVIOR Q SUICIDAL THOUGHTS CD V 0^ SIGNS / SYMPTOMS OF DEPRESSION Q Y CURRENT GRADE AT SCHOOL

DEVELOPMENTAL ASSESSMENT

,_

S 3 AGE AT ASSESSMENT ty'tjr* JWKUEHEIGHT H ji . *' WEIGHT j^ DDST II* SCORE [ IF UNDER 6 YEARS] NORMAL Q SUSPECT Q ABNORMALQ^ PERSONAL/SOCIAL AGE APPROPRIATE R" FINE MOTOR AGE APPROPRIATE Q GROSS MOTOR AGE APPROPRIATE ET LANGUAGE AGE APPROPRIATED

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

~fa

ADDITIONAL FINDINGS

BM/ --^^ . 9'?'^ p^c^au^,

MEDICATIONS

SIGNATURE

TERMS: WNL=Wilhin Normal Limits; GI=GastrointestinaI; GU=Genito-urinary; DDST II Score=Denvtr Developmental 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 regarding HIV testing and has given me written information with the following details 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 subjects from discrimination based on HIV status. My health care provider will talk with me about notifying my sex or needle-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 to additional testing which may occur on the sample I provide today to determine the best treatment for me and to help guide HIV prevention programs. I also agree to future tests to guide my treatment. I understand that I can withdraw my consent for future tests at anytime.

For pregnant women only:


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

~*6~^~-=a..
(Test subject or legally authorized representative) If legal representative, indicate relationship to subject: Printed Name: A-e^-^uC.^,-, -S^i Medical Record #: Ft>r.

Date:

L^"^^^

P,<> 'uJfctLJ,

7~^ -o 5~

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) _

New York state Department of Health

IPAA Compliant Authorization for P ' e of Medical Information 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 medical information, 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-related illness 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 information may also be released to the following: health providers caring for you or your exposed child; health officials when required by law; insurers to permit payment; persons involved in foster care or adoption; official correctional, probation and parole staff; emergency or health care staff who are accidentally exposed to your blood, or by special court order. Under State law, anyone who illegally discloses HIV-related information may be punished 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 are not protected under federal law. For more information about HIV confidentiality, call the New York State Department of Health HIV Confidentiality Hotline 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 on page two (or additional sheets if necessary) of the form, for the reason(s) listed. Upon your request, the facility or person disclosing your medical information 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 of providing 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 for r ,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 Services .. Family & Children's Services Division (Macftrtfaur Building - 3rd Floor) P O Box 18100 ..
Hauppauge, New York 11788
Reason 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 the New York State Division of Human Rights Office of AIDS Discrimination Issues at 1-800-523-2437 or (212) 480-2493 or the New York City Commission 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-related information, and that I can change my mind at any time and revoke my authorization by writing the facility/person obtaining thisrelease.I authorize the facility/person noted on page one to release medical and/or HIV-related information of the person named on page one to the organizations/persons listed. ^~^e-^-^-A- " >fr-g-~(Subject of information or legally authorized representative) / If legal representative, indicate relationship to subject: Signature Print Name Client/Patient Number
DOH-2557(5/05)p2of3

Date

/ / =

01/26/2010 TUB 14:50 FAX 16318549^00

SOCIAL SERVICES C P B

***

TX REPORT

***

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

COUNTY OF SUFFOLK
STEVE LEVY
SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF SOCIAL SERVICES Gregory Blass COMMISSIONER

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: I hereby anthoriie the me and/or disclosure of my protected health information as ecriM Below. I undentead that this authorization hi voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.
To: (Name and address of person, facility, and/or projram discloshjg information) From: (Name, address and title of person and/or organization to which disclosure fat to be made)

\ nsb

Chfld Protective Services TEAM#\~1 P.O. Box 18100 Hauppaute. New York 11788-8900 Information to be released: (Check app gories) Treatment plan Dates of treatment

Psychological/Psychiatric evaluation Laboratory A X-ray reports/results Medical 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 of Alcohol and Drag Abase Patient Records" and cannot be disclosed witirant my consent unless otherwise provided for in the regulations. I understand that I may revoke thb anthorizatioa at any tiiiie by notifying the providing organizatioa in writing, bat if I do it woB't have any effect OB any actioa they took before they received the revocation. 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 H Release 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 TX/RX NO CONNECTION TEL CONNECTION ID ST. TIME USAGE T PCS. SENT RESULT 1785 915167961278 01/26 15:57 03'33 3 OK

COUNTY OF SUFFOLK
STEVE LEVY
SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF SOCIAL SERVICES Gregory Bias* COMMISSIONER

FAX TRANSMITTAL COVER SHEET

Number of pages, including this cover sheetFax Number sent to: ^\U. -T"liL0-\2"/ftD*te: ^'me:

CONFIDENTIALITY NOTICE
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, help fill out forms for hospitals, clinics, food stamps, WIC, Medicaid. Support and follow up for her issues with her work, and help with her personal issues. Paid over $3,000 to fix her tractor trailer, follow up with her license suspension. Fixing her vehicle. I Also purchased a 1996 Ford Windstar minivan to have a second vehicle 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, Bedding Diapers, Baby Wipes, Formula, Baby food, (Jars, Rice Cereal), Clothes, Air Conditioner, Some Baby Bottles, (other basic necessities) Prescriptions, Breast Pump, Thermometer, bibs, wash clothes, baby spoons, 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 abuse towards my mother. Verbal abuse towards my sister. Unfaithful, always refused a paternity test, very demanding 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, cell phone, 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 my daughter, she would tell me to put her down, that she's not mine. If I did not pick up my daughter she would accuse me of being a bad father. I cannot bring my daughter anywhere. Ms. Palmiotti was always present, and I was never left alone with my daughter. My daughter cannot have any contact with any of my 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 the commode and she enters the bathroom and starts pulling and twisting my breasts and chest hair very hard, that incurred bruising, and a week or so after, she stepped on my foot and bruised my toe nail that as of today has not healed correctly, and a few attempts to hit me at my groin area. Other physical abuse 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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Receipt
Ship To: Paul Plsctelli 318 Ellison Ave Westbury, NY 11590 United States Transaction ZD: 66161551PK893091M Seller Information: burkman333 turbo_2@netzero.net

Placed on Oct. 24, 2005


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Item Title girts clothes 12 mos babygap coat oldnavy disney Jeans girts dothes 12 mos babygap arizona Jeans NWT PJ's ect

Price $5.50 USD $9.05 USD

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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 Crib
last modified: Sun, IS Oct 09:44 EOT

Avoid fi:am j|_ jrsid by dealing locally:

(report scam attempts to .abuse@craigslist.Qrg)

non-local deals involving shipping, wire transfer, cashier checks, escrow, or 3rd party payments are usually fraudulent there are no such things as "craigslist payment system", "craigslist buyer protection", or "craigslist seller 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: sale-220868002@craigslist.org Date: 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 has a slight white tint to it. It converts to a toddle bed and has a draw under the crib for storage. The Mattress has 3 levels so its great from a small baby all the way up to a toddler. The crib was purchased for 700.00 plus the mattress and is in excellent condition. It is the same model still out in the Baby Bellini stores. Any questions please contact me. Thank you
this is in or around Garden City no 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)

S00900898 09/16/09 -110 SUFF

SERV 03/16/10 017 108 SN-CSH 10/24/09 11050 1129 NPA-FS 05/31/10 12070 1367

ACTIVE 13706642

ACT

09/16/09

PALMIOTTI WINONA 218 COUL ST. OH 44902 MANSFIELD

2) POOD15547 08/26/09 -B SUFF

CLOSED 13666430

CAS-CL 10/25/09 08/26/09 ACT ACT 11/01/09 11/01/09 CAS-CL

PALMIOTTI WINONA 3085 VETS HWY RONKONKOMA NY 11779

3) FOOD15547 11/01/09 -B SUFF

ACTIVE 13604386 _

PALMIOTTI WINONA 3085 VETS HWY NY 11779 RONKONKOMA

SEARCH COMPLETED

Police Request Tracking System - Incident Request


J Log ID 14753 Request Date j 1/7/2010 4:43:01PM j Priority | (1. Priority Supervisor Phone 631-854-9130 Cancel Reason None Offense | (Check All Court Date 1/20/2010 Division [ FCSA

| |
I I

Supervisor Name Sally O'donnell

Supervisor E-mail j Satly.O'donnelKgdf a.state.ny.us

Team / Worker ID j 17 1 | 108 j

Team Fax [631-854-9347

Processed Date j |None

Completed j 'NO

SCPD Return Type | (None SCPD Comments None


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S SPP Results
Not Found

SCPD - addl Addr j iNo |

SCPD - add! Alias No J

CPS Comments grandparents have petioned for custody of fosterchiid

*-*"

* First Name Phillip Address 24 Femdale Boulevard Total Addresses : 1

Last name Marzocco Address 2

Dob 01/22/1945 , Cit* (slip

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SOUNDEX & PRIOR ARRESTS


state ,NY zip 11751

NEGATIVE

Alias For Individual: None Total Aliases : 0 First Name Carol Address 24 Ferndale Boulevard Total Addresses : 1 Last name Marzocco NJ*~As. "^ Dob 08/27/1947 City (slip

Dup/Loatefo
state NY zip. 11751

Address 2

Alias For individual: None Total Aliases : G

FAXED (^E-MAILED^PU PHONED^ep*a| /"Message DATE iS O i U

1/8/2010

11.09.29AM

InckfentRequestReixxtrpI

Page 1 of 2

COUNTY OF SUFFOLK

STEVE LEVY SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF SOCIAL SERVICES GREGORY J. BLASS COMMISSIONER

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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.

Name: Date of Birth: Address:

Signature

'

Date

BOX 18100

HAUPPAUGE, N.Y. 11788-8900

(631)854-9935

COUNTY OF SUFFOLK

STEVE LEVY SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF SOCIAL SERVICES GREGORY J. BLASS COMMISSIONER

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.

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Name: Date of Birth: Address:

Dat/

BOX 18100

HAUPPAUGE, N.Y. 11788-8900

(631)854-9935

TRANSPORTATION SERVICES REQUISITION/RECORD Case Name: Winona Palmiotti Case Number: S00900898 Court Ordered: Yes Kl No Q Requisition Date: 12/29/09 Child/Children and DOB: Winona Piscitelli I Deliver items [ Drop off records

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

Visit or Activity to Commence on: Friday 1/15/10 Frequency of Visit: ^]l time Qweekly Obi-weekly Qmonthly Length of Visit: 1.5 hours Time of visit: (check) [/3am CHafternoon Oevening dJSaturday (IF VISIT MUST BE A SPECIFIC TIME OR DAY, PLEASE INDICATE): Foster Parent or Custodian: Addres Home Phone: Person(s) Authorized to have visit and relationship to children: Mother Winona Palmiotti Home 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) dAsthma QSeizure disorder C]Other QSpecial 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

SC CPB

IfiOOl

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

TRANSMISSION OK TX/RX NO CONNECTION TEL SUBADDRESS CONNECTION ID ST. TIME USAGE T PCS. SENT RESULT 0955 99208468

12/28 11:59 02 '46 16 OK

COUNTY OF SUFFOLK
LEVY
SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF SOCIAL SERVICES Gregory BlMs COMMISSIONER

FAX TRANSMITTAL COVER SHEET

From:
To:

Ntmber of pages, including this cover sheet: \ r Faw Number sent to: n /.. . . Date:

Time:

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

.OUNTY OF SUFFOLK

STEVE LEVY SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF SOCIAL SERVICES GREGORY J. BLASS COMMISSIONER

December 28, 2009 Pederson Krag 11 Route 111 Smithtown,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 as possible. Ms. Palmiotti does not have medical insurance. Please work with Ms. Palmiotti on a sliding scale for your 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 Neglect Petition 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, Caseworker Child 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 TX/RX NO CONNECTION TEL CONNECTION ID ST. TIME USAGE T PCS. SENT RESULT 1491 99208468 12/28 09:50 00'41 2 OK

COUNTY OFSUFFOLK
STEVE LEVY
SUFFOLK COUNTY EXECUTIVE DEPARTMENT OF SOCIAL SERVICES Gregory Blass COMMISSIONER

FAX TRANSMITTAL COVER SHEET


Date: From:

Number of pages, including this cover sheet: Fax Number sent to:q^/vv_cjyjr ^ Date:

. Time:

CONFIDENTIALITY NOTICE
The documents which accompany this telefax transmission sheet contain

TRANSPORTATION SERVICES REQUISITION/RECORD Case Name: Winona Paimiotti Case Number: S00900898 Court Ordered: Yes ^ No Q Requisition Date: 12/17/09 Child/Children and DOB: Winona Piscitelli CH Deliver items l~1 Drop off records

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

Visit or Activity to Commence on: Week of 12/28 Frequency of Visit: 131 time [^weekly Qbi-weekly l~1monthly Length of Visit: 2 hours Time 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 Paimiotti Home Phone: 516-238-0371 Cell: PICK UP location(s) (list all) Visitation Site/Address: dss RETURN location(s)t|

DEC 1 7 2009

8 Please check all that apply: Child Placement Bureau QOrder of Protection (Attach copy) Sunb!k County Sods! Ssrvices LjLetter from custodian giving permission for DSS to transport (Attach copy) [^Individuals not permitted at visit:
MEDICAL INFORMATION (check all that apply, please note individual with condition/allergy): IZlAIlergy (list allergy) OAsthma , ^ \~ |J i^ \ f ^ DSeizure disorder Dother QSpecial equipment DNone Comments: One time make up visit for any day /anytime this week. CSW Josephine is off. Normal visit is Wed 1:303:30, However a morning visit is also good for all Mother is severly mentally ill. CSW must watch and listen very closely aseworker: Lori Towns Assigned to: V1 Clp <UA Team# 17 C-^P x; 'fO' Start Date: Extension: 4-9397 IO|3b|cO Time:
Q. QCn.

/^

Transportation Unit cannot handle request at this time:

Transportation Coordinator

Date

COUNTY OF SUFFOLK

STEVE LEVY SUFFOLK COUNTY EXECUTIVE


DEPARTMENT OF SOCIAL SERVICES

JANET DEMARZO COMMISSIONER

PERMISSION FOR RELEASE OF INFORMATION


I hereby authorize

fY
and

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

V\

CLkJL
I understand that the information to be released is confidential ana protected from disclosure. I understand that I have the right to cancel this Permission for Release of Information at anytime before it is released. I also understand that this Permission for Release of Information will expire when acted upon, or six months, whichever comes first.

Relationship: *T&\ j Address:

Etete

BOX

181OO

HAUPPAUGE, N.Y. 1I788-B9OO

(631)854-9935

\- HOSPITAL MEDICAL CENTER Member of Catholic Health Services of Long Island


WHEN CAKING MATTERS
A MAGNET" DESIGNATED HOSPtTAl

SAMARITAN

Nursing's Highest Honor

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

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 Medical Center. This four week series focuses on issues relating to parenting children ages birth through five and includes the following topics: communicating with your child, instilling self-esteem, positive discipline techniques, nurturing social and emotional development and fostering cooperation. The dates were as follows: Thursday, Thursday, Thursday, Thursday, November December December December 19, 3, 10, 17, 2009 2009 2009 2009

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

Sincerely,
7X /*** / ^}^r*~<-> S '

Karen Kaplan, MS, RN Perinatal Education Coordinator

; HOSPITAL MEDICAL CENTER A Member of Catholic Health Services of Long Island


WHEN CARING MATTERS A MAGNET-DESIGNATED HOSPITAt (631) 376-4444 www.good-samaritan-hoapital.otg

SAMARITAN

Nursing's Highest Honor

November 19, 2009

To Whom it May Concern; 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 Medical Center. This four week series focuses on issues relating to parenting children ages birth through five and includes the following topics: communicating with your child, instilling self-esteem, positive discipline techniques, nurturing social and emotional development and fostering cooperation. The dates of the series are as follows: Thursday, Thursday, Thursday, Thursday, November December December December 19, 3, 10, 17, 2009 2009 2009 2009

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

Sincerely,

Karen Kaplan, MS, RN Perinatal Education Coordinator

IS HOSPITAL MEDICAL CENTER A Member of Catholic Health Sendees of Long Island


WHEIV CARING MATTERS A MAGNET-DESIGNATED HOSHTAl (631) 376-4444 www.good-sama-itan-hoSpitjI.org

AMARITAN

Nursing's Highest Honor

, . .October 30, 2009

To Whom it May Concern; 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 Medical Center. This five week series focuses on issues relating to parenting children ages birth through five and includes the following topics:, communicating with your child, instilling self-esteem, positive discipline techniques, nurturing social and emotional development and fostering cooperation. The dates of the next series are as follows: Thursday, Thursday, Thursday, Thursday, Thursday, ;;,;; November November
! ' ( :'i : . * ' . ' ' :

12, 19, 3, 10, 17,

2009 2009 2009 2009 2009

December December December

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

Sincerely,

Karen Kaplan, MS, RN Perinatal Education Coordinator

I, VI \(NQQ>^\\T^yf^6nJ\V hereby acknowledge that on \2.l < \/ 0^ an I discussed the need for me to participate in: ' and I I Psychotherapy Drug Rehabilitation Alcohol Rehabilitation Parent Training Other (specif

mY caseworker

I understand that my participation in the above satisfied the conditions of my: n Court Order I Voluntary Placement Agreement ^BxJUniform Case Record Plan I have been given the following resources:

cfr V\e^r^ WolftK cfr ^ue^r^.

I understand that failure to follow the above stipulations constitutes failure to plan for my child 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. IF YOUR CHILD STAYS IN FOSTER CARE FOR IS OF THE MCST RECENT 22 MONTHS. THE AGENCY MAY BE REOUIRED BY LAW TO FILE A PETITION TO TERMINATE YOUR PARENTAL RIGHTS AND MAY FILE BEFORE THE END OF THE 15 MONTH PERIOD.

MENTAL HEALTH CLINICS

Brentwood Mental Health Center J841 Brentwood Road, Brentwood, NY11717 Brookhaven MHC : Access Center Shirley Center 550 Montauk Highway, Shirley, NY, 11967 Mon-Wed 9-8PM Thurs.-Fri. 9-5PM Patchogue Center 365 E. Main Street, Patchogue, NY11772 Buckman Center - Brentwood Pilgrim Psych Center, Bldg 47 998 Crooked Hill Road, W. Brentwood, NY 11717 Catholic Charities: Bay Shore Center 9 Fourth Avenue, Bay Shore, NY 11706 Medford Center 1727 North Ocean Avenue, Medford, NY 11763 Children and Family Mental Health Services: East 221 Broadway - Suite. 205, Amityville, NY 11701 West 37 John Street, Amityville, NY, 11701 School Based Program 37 John Steel, Amityville, NY, 11701 Wyandanch 1449 Straight Path, Wyandanch, NY, 11798

853-7300

447-3048 852-1070

854-1222

761-2289

665-6707

654-1919

598-4726

264-4325

264-4325

253-0376

13