IFSP

Individualized Family Service Plan (IFSP)

IFSP Date

IFSP Type

IFSP Period:

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 does the 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?

1. Provider progress notes

1. Parent report

1. 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

· Continue with 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?

1. Provider progress notes

1. Parent report

1. 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

· Continue with 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 Move Intervention 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: _______________ IFSP MEETING DATE: _______________

Name

Agency

Phone Number

Role

Method of Attendance