Special Education

Ken Kang

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EARLY START PROGRAM

San Joaquin County Five Points of Contact

Stockton Unified School District - - - - - - - - - - - - - - (209) 933-7315 x7745

Lodi Unified School District - - - - - - - - - - - - - - - - - (209) 331-7366

San Joaquin County Office of Education - - - - - - - - - (209) 931-4514

Valley Mountain Regional Center - - - - - - - - - - - - - (209) 473-0951

Family Resource Network - - - - - - - - - - - - - - - - - - - (209) 472-3674

I ndividual Family Service Plan (IFSP)

IFSP Date: *md Meeting Location: *ml

Referral Date: *rd Intake interview Date: *itd Last IFSP: *pid

6 month review by: *6mr Transition Plan by: *tp IEP/IPP by: *iep

Child’s Name: *fn *ln VMRC#: *uci

DOB: *dob Age: *mAge months Adj. Age: months Sex: *sex

Ethnicity: *eth Primary Language: *pl Interpreter: *trans

Health Insurance:

Parent(s): *mfn *mln & *ffn *fln

Address: *address (Mail to *maddress)

Phone(s): *phone1*phone2

e-mail: *email

Resides with: , , , , ,

Guardian: Phone: (209) , Fax (209)

School District: *sd SELPA: *selpa

Early Start Eligibility

*fn’s Early Start eligibility determination was based on the review of pertinent medical records and/or results of our initial evaluation(s) completed by qualified personnel. Applicable item(s) is/are checked below.

Developmental Delay –% or greater delay(s) in , , , , skills

Established Risk –medical diagnosis that is likely to result in developmental delay:

High Risk –

Informed Clinical Opinion –

Solely Low Incidence (SLI) –

Suspected of SLI –Intake Coordinator to refer *fn to LEA

Qualifies for

Not eligible for Early Start Program

Tell us about your child and family (parent statement)

You (*mfn and *ffn) do not have to give any information on this section in order to receive services. However, information provided will help us develop meaningful outcomes for *fn and you, based on your family routines and focus.

What does *fn do well? (Strengths)

What interests or motivates *fn? What are *herhis favorite things? What does *shehe like to do? (cont’d Strengths)

What is difficult about your daily routine? What would you like to change? (Concerns & Needs)

How/Where do *fn and you spend your day together? (Natural Environment)

What people or community resources are helpful to your family? Are there other resources you would like to learn more about? (Resources)

What would you like the intervention team to focus on? Is there anything you would like to have *fn or family do next? (Priorities)

What is your family interested in learning more about? (cont’d Priorities/Resources)

Child Health Information

Current Primary Physician:

Specialists:

Summary of *fn’s Health Status based on review of pertinent records (including birth history, medical conditions and diagnosis (if any), illnesses, hospitalizations, medications and any relevant evaluations.

*fn has enjoyed excellent health since birth. *shehe has no history of recurring ear infections and/or upper respiratory infections

Current Medications: None

What else should your team know about *fn’s health so that we can better plan and provide services for *herhim and your family? (current medical concerns, immunizations, allergies, sleeping concerns)

*fn has no unusual prenatal and neonatal medical history.

No No

Nutrition, Diet, Eating Preferences, Oral-Motor Concerns

*fn takes ounces every hours. *shehe also takes , , and .

*shehe .

*fn eats with , and drinks from and only at nap and bed time.

*shehe has no

Current weight: pounds ounces th percentile

Current height: inches th percentile

Head circumference: inches th percentile

Immunizations:

Additional Information

Autism screening (M-CHAT) was completed with parent’s input by *ier on *itd. The results were non-critical and critical failed responses.

Behavioral Observations

*itd

*md, during evaluation/assessment

Steps to Transition

· *ier, Intake Coordinator, informed *mfn and *ffn that the Early Start Program serves children from birth to third birthday.

· IFSP team will be promoting developmental skills, that will help *fn be ready for preschool, such as staying on task, imitating actions/sounds, following instructions, taking turns, etc.

Use of Private Health Insurance

Parent/Family was advised that *fn’s private insurance or health care service plan is required to be accessed to pay for medical (therapy, nursing, etc.) services specified in the IFSP, other than for evaluation and assessment. (TBL Section 1:Gov. Code Section 95004)

+ =Assessments Used/Professional’s Title/Date

On *fmd, *fn was evaluated at *ml by using the . The evaluation included observation, parent interview and medical record review as applicable.

In accordance with Educational Code 56320, the following was considered regarding the procedures and materials used during this evaluation to ensure compliance with state and federal regulations:

This evaluation was conducted by qualified persons. Test and assessment materials and procedures used for the purposes of assessment and placement of individuals with exceptional needs were selected and administered to as not to be racially, culturally, or sexually discriminatory. The student’s dominant language was considered in selecting assessment instruments. Tests have been validated for the specific purpose for which they were used. Tests and other assessment materials include those tailored to assess specific areas of educational need and not merely those that are designed to provide a single, general intelligence quotient. The assessment results that have been provided accurately reflect the student’s current skills in the area of gross and fine motor, cognitive, communication, social/emotional and adaptive behavior.

CHILD’S NAME will participate in Statewide Assessment Program through DRDP access two times per year using no adaptations (if yes, list adaptions)

Review of Prior Outcomes:

*fn’s Present Levels of Development+

Domains & Subdomains

What *fn does now and *herhis next step

Adaptive

Self-Care

Personal Responsibility

Next Step :

Personal-Social

Adult

Interaction

Peer Interaction

Self-Concept and

Social Role

Next Step :

Communication

Receptive

Expressive

Next Step :

Motor

Gross Motor

Fine Motor

Perceptual Motor

Next Step :

Cognitive

Attention & Memory

Reasoning &

Academic Skills

Perception &

Concepts

Next Step :

Hearing *fn the Music 2 My Ears hearing screen by responding to all sounds of the screening kit.

Vision *fn the Functional Vision Screening.

Child Outcomes

(What does *fn need to accomplish in order to participate in a family routine and/or activity?)

Outcome # We want *fn to

We will know progress is made when (Criteria).

Review by *tod (Timeline)

The team plans on measuring *herhis progress by , (Procedures for Measurement).

What are the ways in which your family and team will work toward achieving this outcome?

Who will help and what will they do? (Strategies- the methods and strategies used to support your child and family in order to achieve your outcomes within your daily activities and routines):

The informal supports may include family members, friends, neighbors, church or other community organizations, special health care programs, parent education program, etc.

Family Outcomes

(What will you need in order to help meet the developmental needs for *fn?)

Outcome # will .

We will know we’ve succeeded when (Criteria for Progress).

Review by *tod (Timeline)

The team plans on measuring progress by (Procedures for Measurement).

Corresponding Outcome #

Services

to achieve outcomes, & Method

Service Provider

contact information

Location

(If not natural settings, why)

Intensity

Frequency

Length

Duration

(& any plans

for service interruption)

Funding Source

Required

Non- required/

Other

Name: *fn *ln Date: *md Page 3 of 6

I ndividual F amily S ervice P lan

Service Summary

IFSP Date: *md Meeting Location: *ml Service Coordinator: *sc

Child’s Name: *fn *ln DOB: *dob VMRC#: *uci

Eligibility Findings Review of IFSP dated *pid

Developmental Delay –% or greater delay(s) in , , , , skills

Qualifies for

Not eligible for Early Start Program

Services Considered on the IFSP




	I to a referral and sharing of my contact information with Family Resource Network (FRN)
	I understand that my private insurance or health care service plan is required to be accessed to pay for medical (therapy, nursing, etc.) services specified in the IFSP, other than for evaluation and assessment. (TBL Section 1:Gov. Code Section 95004)
	I have received the summary of parent information, rights, appeals procedures, protecting your child’s confidentiality, VMRC Whistleblower policy and Family Resource Network brochure, and have had them explained to me
	I have been given AFPF information. I have been assessed the AFPF fee and received forms 6009 and 6010
	I have received a copy of my annual financial statement
	I agree with the Individual Family Service Plan (IFSP) developed today, and I authorize IFSP team members to exchange information with service providers to promote team work for my child
	I understand that a final typed copy of this IFSP and the signed cover sheet will be mailed to me within 30 days.
	I have received a copy of the IFSP today.
	It is my responsibility to notify my SC if I do not agree with the final typed IFSP document. A new IFSP development meeting will be scheduled within 15 days to discuss changes to the IFSP
	I disagree with a portion of the IFSP. I authorize VMRC to implement all services stated in the IFSP except . . A new IFSP development meeting is scheduled for
IFSP Team Members: (letter code in box indicates: A ttended, C onference, T elephone input, W ritten input)

Name Signature Title / Agency Phone Date Copy to
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Helping People with Developmental Disabilities Reach Their Maximum Potential

Stanislaus County

Branch Office

1820 Blue Gum Avenue

Modesto, CA 95358

Phone: (209) 529-2626

Fax: (209) 557-2174

Amador, Calaveras, and Tuolumne Counties

Branch Office

704 Mountain Ranch Road, Suite 203

P. O. Box 1420

San Andreas, CA 95249

Phone: (209) 754-1871

Fax: (209) 754-3211

San Joaquin County

Main Office

702 N. Aurora St.

P. O. Box 692290

Stockton, CA 95269-2290

Phone: (209) 473-0951

Fax:

· Administration: (209) 473-0256

· Case Mgmt: (209) 473-0719

· Clinical: (209) 956-6439

Meeting Confirmation Notice

Date:

Ms. *mfn *mln

Mr. *ffn *fln

*address

Mail to *maddress

*phone1*phone2

RE: *fn *ln

DOB: *dob

Dear Ms. *mln and Mr. *fln:

This letter is to confirm our meeting that we discussed.

Annual Review

6-Month Review

Transition Plan

Quarterly Review

Exit IFSP Review

Other:

Meeting Date: *fmd

Time:

Location: *ml

We know that you want to be involved in making plans for *fn. This meeting will give us an opportunity to discuss services for *herhim. Staff and administrators from the agencies that serve *herhim have been invited to attend the meeting. You may bring a friend or relative with you to the meeting if you wish. Please phone me at *psc if you have any questions or concerns.

As a result of recent changes in legislation in government code section 95020 and Sections 4646 and 4646.5, Valley Mountain Regional Center (VMRC) is required to obtain copies of all consumers’ medical insurance cards annually (including Medi-Cal, Medicare, and private insurance). If you have not given us a copy of your most current insurance card, please have a copy available for the visit.

Sincerely,

*sc, Early Start Service Coordinator

cc:

Helping People with Developmental Disabilities Reach Their Maximum Potential

San Joaquin County

Main Office

702 N. Aurora St.

P. O. Box 692290

Stockton, CA 95269-2290

Phone: (209) 473-0951

Fax:

· Administration: (209) 473-0256

· Case Mgmt: (209) 473-0719

· Clinical: (209) 956-6439

Stanislaus County

Branch Office

1820 Blue Gum Avenue

Modesto, CA 95358

Phone: (209) 529-2626

Fax: (209) 557-2174

Amador, Calaveras, and Tuolumne Counties

Branch Office

704 Mountain Ranch Road, Suite 203

P. O. Box 1420

San Andreas, CA 95249

Phone: (209) 754-1871

Fax: (209) 754-3211

Date: *fmd

Child’s Name:	fn ln
DOB:	*dob
Health Care Provider:

Dear Health Care Provider:

I am requesting the medical record of from to present for the purpose of developing the Individual Family Service plan (IFSP) based on her current needs. Enclosed is a copy of the signed Release of Information.

Please send the record to:

Valley Mountain Regional Center

1820 Blue Gum Ave

Modesto, CA 95358

Attn: *sc

[Fax] (209) 557-2174

702 N Aurora St

PO Box 692290

Stockton, CA 95369-2290

[fax] (209) 473-0719

704 Mountain Ranch Road, Suite 203

P. O. Box 1420

San Andreas, CA 95249

[Fax] (209) 754-3211

Thank you very much for your time and prompt action.

Sincerely

*sc

Early Start Service Coordinator

Enclosure