iep

Sample Individualized Family Service Plan

I. Child and Family Information Child’s Name Maria Ramirez Date of Birth 12-9-14 Age in Months 30 Gender F

Parent(s)/Guardian(s) Bruce & Catherine Ramirez Address 2120 Valley Park Place Middletown, IN 46610

Street City Zip Code

Home Telephone No. (513) 555-0330 Work Telephone No. (513) 555-1819

Preferred Language English Translator Appropriate Yes X No

II. Service Coordination Coordinator’s Name Susan Green Agency Indiana Early Intervention Program

Address 105 Data Drive Burlington, IN 46980 Telephone No. (513) 555-0214

Street City Zip Code

Appointment Date 6-16-17

III. IFSP Team Members Name Agency Telephone No. Title/Function

Susan Green Indiana Early Prevention (El) Program 513-555-0214 Service Coordinator

Mr. and Mrs. B. Ramirez N/A 513-555-0330 Parents

Barbara Smith Indiana El Program 513-555-0215 Speech/Language Pathologist

Martha Kind Indiana El Program 513-555-0213 Occupational Therapist

Libby Young Middletown Preschool Program 513-555-3533 Preschool Teacher

IV. Review Dates Date of IFSP 6-16-17 Six-Month Review 12-15-17 Annual Evaluation Not applicable

V. Statements of Family Strengths and Resources Maria’s parents are well-educated professional individuals with realistic goals for her educational development. The entire family unit, including her grandparents, are committed and motivated to assist her in any way. Because of the family’s geographic location, limited resources are available for service delivery at this time.

VI. Statements of Family Concerns and Priorities Concerns Due to Maria’s medical diagnosis of Down syndrome, her parents are concerned about appropriate early intervention services to assist in ameliorating her developmental delays. Additionally, the parents have stated a reluctance about a change in Maria’s service delivery from her natural environment (i.e., her home) to an inclusive community-based preschool.

Priorities The priorities that Maria’s parents have for her include improving her communication skills, her ability to use utensils, and her toileting skills. They desire services to be delivered at home with the eventual goal of a placement with typical children who attend the local kinder- garten. Her parents and grandparents want to learn ways in which they can help to facilitate Maria’s development in her natural environment.

VII. Child’s Present Level of Development and Abilities Cognitive Skills (Thinking, reasoning, and learning) Maria’s cognitive abilities are commensurate with a 20-month-old child. She’s extremely inquisitive and understands simple object concept skills. Imitative play is consistently observed; however, discrimination of objects, persons, and concepts continues to be an area of need.

Communication Skills (Understanding, communicating with others, and expressing self with others) Communication/language competency skills appear to be similar to that of an 16-month-old toddler. Her receptive language is further developed than her expressive abilities. Primitive gestures are her primary mode of communication. She consistently exhibits a desire/ interest to interact with others. Verbal responses primarily consist of vocalizations and approximations of single word utterances (e.g., ma-ma, da-da, ba-ba),

Self Care/Adaptive Skills (Bathing, feeding, dressing, and toileting) Feeding, in general, such as drinking from a cup and finger feeding, is appropriate at this time. A great deal of assistance from caregivers is still required for daily dressing tasks and toileting.

Gross and Fine Motor Skills (Moving) Maria appears to be quite mobile. She is adept at rambling and walking, but needs to improve muscle strength and endurance. She enjoys movement to music. She can scribble, grasp large objects, turn pages of books, and prefers using her right hand while performing tasks. She needs to work on her ability to use utensils and writing tools.

Social-Emotional Development (Feelings, coping, and getting along with others) Maria is a very happy, affectionate, and sociable child. She enjoys being the center of attention and engaging in interactive games; how- ever, she appears content to play alone. Temper tantrums are triggered by frustration from her inability to communicate. Sharing and turn taking continue to be difficult for Maria,

Health/Physical Development (Hearing, vision, and health) Maria’s general health is good, but she has a history of chronic otitis media and upper respiratory infections. Vision and hearing are monitored frequently.

VIII. Outcome Statements 1. Participate in stimulation of all language modalities (visual, auditory, tactile) in order to increase communication competency.

Strategies/Activities Responsible Person/Agency

Begin Date

End Date

Frequency of Service Location

Evaluation Criteria

1.1 Maria will use word approximations combined with consistent gestures for 5 different needs across 3 different people and 2 different settings.

SLP 6-19-17 12-15-17 Once weekly

Home Preschool Language Scale

1.2 Maria will use words combined with signs for 5 different needs across 3 different people and 2 settings.

Mom and Dad 6-19-17 12-15-17 Observation samples

2. Maria’s daily self-care skills will improve in the areas of dressing and toileting abilities.

Strategies/Activities Responsible Person/Agency

Begin Date

End Date

Frequency of Service Location

Evaluation Criteria

2.1 Maria will push down/pull up under- garments with minimal assistance.

Mom and Dad Service Coord.

6-19-17 12-15-17 Once weekly Home Observations

2.2 Maria will establish a consistent pattern of elimination.

Mom and Dad Service Coord.

6-19-17 12-15-17 Once weekly Home Recorded data of frequency of elimination

2.3 Maria will spontaneously indicate by gesture and vocalization the need for going to the restroom.

Mom and Dad Service Coord.

6-19-17 12-15-17 Once weekly Home Observation samples

3. Maria will develop improved abilities to discriminate auditorv/visual stimuli.

Strategies/Activities Responsible Person/Agency

Begin Date

End Date

Frequency of Service Location

Evaluation Criteria

3.1 Indicate by pointing/verbalizing whether objects are the same or different.

Mom and Dad Service Coord.

6-19-17 12-15-17 Once weekly Home Observations

3.2 Sort several colors and shapes consistently.

Mom and Dad Service Coord.

6-19-17 12-15-17 Once weekly Home Observation samples

3.3 Imitate words and motions in songs upon being given a model.

Mom and Dad Service Coord.

6-19-17 12-15-17 Once weekly Home Observation samples

IX. Transition Plans If eligible, the following steps will be followed to transition Maria Ramirez to Part B services on or about child’s name 1-3-18

projected transition date

1. The service coordinator will schedule meeting with parents to explain the transition process and rationale, review legal rights, and ascertain their preferences and need for support.

2. The service coordinator will arrange for Maria and her parents (and grandparents) to visit the center and meet teachers, staff, and children.

3. The service coordinator will arrange for Maria to visit her classroom on at least three occasions in the month prior to her transition date. 4. At least 90 days prior to Maria’s third birthday, the service coordinator will convene a meeting to further develop Maria’s

transition plan.

X. Identification of Natural Environments The home environment is considered to be Maria’s natural environment at this time.

Justification for not providing services in natural environment: Not applicable.

XI. Family Authorization We (I) the parent(s)/guardian(s) of Maria Ramirez hereby certify that we (I) have had the opportunity to participate in the development of our (my) son’s/daughter’s IFSP. This document accurately reflects our (my) concerns and priorities for our (my) child and family.

We (I) therefore give our (my) permission for this plan to be implemented. X Yes No

Catherine Ramirez 6-16-17 Bruce Ramirez 6-16-17 signature of parent/guardian date signature of parent/guardian date

SOURCE: Adapted from R. Gargiulo and J. Kilgo, An Introduction to Young Children with Special Needs (4th ed.) (Belmont, CA: Wadsworth/Cengage Learning, 2014), pp. 327-330.