|
Individualized Family Service Plan (IFSP)
|
|
|||||||
| Section 1- A: Child Information | ||||||||
| Child’s Name
|
Date of Birth / / |
Gender:
Male Female |
||||||
| AKA Name | Child ID | MOSIS ID | ||||||
| County | School District | |||||||
| Section 1 – B: Family Contact Information | ||||||||
| Primary Contact Name | Relationship to child:
|
|||||||
| Mailing Address
|
Phone
|
|||||||
| Physical Address
|
Language: | |||||||
| Other Contact:
|
Relationship to the child: | |||||||
| Mailing Address
|
Phone
|
|||||||
| Section 1-C: First Steps Contact Information | ||||||||
| Service Coordinator | Agency Name | |||||||
| Address
|
Phone | |||||||
| Primary Provider
|
Agency Name | |||||||
| Email Address | Phone | |||||||
|
Section 1-D: Getting to Know Your Family |
||||||||
|
Who is included in your family?_________________________________________________________________ What is your favorite time/activity with your child?____________________________________________________ What is the best time of day for your family?_______________________________________________________ What is your family’s most challenging time of day?_________________________________________________ What does your family like to do together? ________________________________________________________ What activities would your family like to participate in? _______________________________________________ Who are the important people in your family’s life? _________________________________________________ Where does your family usually spend time during the week?____________________________________________ Where does your family usually spend time on the weekends?_________________________________________ Is your family enrolled in PAT? __Y __ N Parent Educator: _______________________________________ Does your child attend child care? __ Y __ N Attendance Days: M T W Th F Sa Su Hours:_____________________________________________ Caregiver : ___________________________________________ Location: ___________________________ |
||||||||
| Section 2: Health and Medical (including vision and hearing) | ||||||||
|
General Health Information
|
||||||||
| Primary Reason for Eligibility in First Steps | ||||||||
| Physicians | ||||||||
| Primary Care Physician Name
|
Address/Phone | |||||||
| Other Physician or Specialist | Address/Phone | |||||||
| Hearing Information | Vision Information | |||||||
| Child has had a hearing test Yes No
(If yes) Date of exam: _______________ Doctor Name: _______________ Doctor Address:______________ Results: Pass Fail Follow-up needed Unsure Has the child passed the Newborn Hearing Screening? Yes No Unknown |
Child has had a vision test Yes No
(If yes) Date of exam: _______________ Doctor Name: _______________ Doctor Address:______________ Results: Pass Fail Follow-up needed Unsure
|
|||||||
|
RISK FACTORS FOR HEARING LOSS
These are family and medical history details for infants and toddlers who are at risk of late onset or progressive hearing loss. |
RISK FACTORS FOR VISION LOSS
These are family and medical history details that have a high incidence of vision loss in infants and toddlers. |
|||||||
|
£ Family history of permanent childhood hearing loss £ Premature birth of 36 weeks or less £ Medical history of infection or trauma £ Post natal infection; such as bacterial meningitis £ Recurrent/persistent otitis media (ear infection) for at least 3 months £ Eustachian tube dysfunction £ Medical condition associated with hearing loss £ Child does not respond to name when called £ Child does not react to loud noises or toys with noise £ Child stands near objects (i.e., radio) to hear sound
Parent / Caregiver concern or observation
|
£ Family history of eye condition (other than glasses) £ Premature birth of 36 weeks or less £ Seizure disorder £ Does not notice people or objects when placed in certain areas £ Eyes make constant, quick movements or appear to have a shaking movement £ Brings objects to one eye rather than using both eyes to view £ Covers or closes one eye frequently
If child is older than 6 months: £ Tilts or turns head to one side while looking £ Cannot see a dropped toy £ Eyes appear to turn inward, outward, upward or downward £ Responds to toys only when there is an accompanying sound £ Moves hand or object back and forth in front of eyes £ Consistently over or under reaches £ Squints, frowns or scowls when looking at objects
Parent/Caregiver concern or observation
|
|||||||
|
Section 3: Present Levels of Development in Daily Routines and Activities |
||||
| Routine | Task Difficulty | Activity | Developmental Areas
|
|
| Wake Up
|
£ Easy
£ Some Concerns £ Difficult |
What’s working well:
What’s not working well: |
£ Communication
£ Movement/ Physical £ Learning/ Cognition £ Social/ Emotional/ Behaviors £ Self-help/ Adaptive |
|
| Dressing / Toileting
|
£ Easy
£ Some Concerns £ Difficult |
What’s working well:
What’s not working well:
|
£ Communication
£ Movement/ Physical £ Learning/ Cognition £ Social/ Emotional/ Behaviors £ Self-help/ Adaptive |
|
| Mealtime | £ Easy
£ Some Concerns £ Difficult |
What’s working well:
What’s not working well:
|
£ Communication
£ Movement/ Physical £ Learning/ Cognition £ Social/ Emotional/ Behaviors £ Self-help/ Adaptive |
|
| Outings
|
£ Easy
£ Some Concerns £ Difficult |
What’s working well:
What’s not working well:
|
£ Communication
£ Movement/ Physical £ Learning/ Cognition £ Social/ Emotional/ Behaviors £ Self-help/ Adaptive
|
|
| Play
|
£ Easy
£ Some Concerns £ Difficult |
What’s working well:
What’s not working well:
|
£ Communication £ Movement/ Physical £ Learning/ Cognition £ Social/ Emotional/ Behaviors £ Self-help/ Adaptive
|
|
| Bathtime | £ Easy
£ Some Concerns £ Difficult |
What’s working well:
What’s not working well:
|
£ Communication
£ Movement/ Physical £ Learning/ Cognition £ Social/ Emotional/ Behaviors £ Self-help/ Adaptive |
|
| Routine | Task Difficulty | Activity | Developmental Areas
|
|
| Bedtime/ Naps | £ Easy
£ Some Concerns £ Difficult |
What’s working well:
What’s not working well:
|
£ Communication
£ Movement/ Physical £ Learning/ Cognition £ Social/ Emotional/ Behaviors £ Self-help/ Adaptive |
|
| Other Routine | £ Easy
£ Some Concerns £ Difficult |
What’s working well:
What’s not working well:
|
£ Communication
£ Movement/ Physical £ Learning/ Cognition £ Social/ Emotional/ Behaviors £ Self-help/ £ Adaptive
|
|
| Section 4: Family Assessment |
| The family chooses to share information about their concerns, priorities and resources and/or include this information in the IFSP. The family understands that if their child is eligible, s/he can still receive services if they do not complete this section. The family gave permission?
Yes No Date: _____________________
|
|
What are the family’s concerns? ______________________________________________________________ Of the concerns, what would the family like to focus on (priorities)? _________________________ What resources doesthe family use? _______________________________________________________
|
| Section 5: Outcomes | ||||||
|
Child Outcome # _____ |
||||||
|
___________________will __________________ by _______________________________________. We will know _________________ can do this when ___________________________________________________________________.
|
||||||
|
Strategies and Activities:(Include activity settings, people, and everyday routines of the child and family).
|
||||||
| How does the team plan on measuring progress?
£ Provider progress notes £ Parent report £ Service Coordinator contact with family
|
When will progress toward the outcome be measured?
£ Each week £ Monthly £ 6 month review
|
|||||
|
Outcome
review date___________
|
Modification to Outcome
|
£ Yes
£ No |
||||
| Outcome Status
|
£ Continuewith Changes
£ Continue as written £ Discontinue |
|||||
| Summary of Progress |
|
|||||
|
Family Outcome # _____
|
|||
|
________________________________________________________________________________________________
|
|||
|
Strategies and Activities: What strategies will we work on together toward this outcome?
|
|||
| How does the team plan on measuring progress?
£ Provider progress notes £ Parent report £ Service Coordinator contact with family
|
When will progress toward the outcome be measured?
£ Each week £ Monthly £ 6 month review
|
||
|
Outcome
review date ___________
|
Modification to Outcome
|
£ Yes
£ No |
|
| Outcome Status
|
£ Continuewith Changes
£ Continue as written £ Discontinue |
||
| Summary of Progress |
|
||
| Section 6: Services and Supports Needed to Achieve Outcomes | ||||||
|
Service Type/
Method/ Intensity |
To help with Outcome | Location | Frequency/Length | Provider Name | Funding Source | Duration |
| Primary Setting for Services (Most services occur here): _________________ | ||||||
| Section 7: Natural Environment | ||||
| Outcome # | Service | 1. Discuss Why Service Cannot be Provided in Natural Environment. | 2. Describe How the Intervention will be Generalized into Child’s and Family’s Daily Activities. | 3. Identify Steps for a Plan to MoveIntervention into a Natural Environment. |
|
|
|
|
||
| Section 8: Other Services and Supports | ||||
|
Service
|
Description | Person Responsible | Steps to Assist | Start and End Dates |
| Section 9: Team Communications |
|
|
| Section 10: Transition | |
| Anticipated Date of Transition: | |
| Transition Topic | Transition Activities |
| 1. Discussion with parent regarding what “Transition” from Early Intervention means. | |
| 2. Dates the directory
information and IFSP/ evaluations/assessments sent to LEA or date parent opted out. |
|
| 3. Discuss Transition Plan,
including options, steps and services to help prepare for a new setting. |
|
| 4. Discuss Transition
Conference with LEA, include C and B differences, LEA contact info and eligibility process. |
|
| 5. Other transitions or changes for the family. | |
| 6. Summer 3rd Birthday: discuss
school readiness including reading, language and counting skills. |
|
| Section 11: Attendance | ||||
|
IFSP MEETING TYPE: _______________ |
||||
|
Name
|
Agency | Phone Number | Role | Method of Attendance |
