Individualized Family Service Plan (IFSP) by 3gz600u

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									                                                               Individualized Family Service Plan
                                                                       Family Information
Referral Date:                         /            /

Child:               ,                                                            Date of Birth:
                                                                                                                    Gender:         M                    F
Last Name / First Name / MI                                                            /       /
Address:                                                                          County:                           Language spoke in home:
      ,
City / State / Zip                                                                District:                         Child in foster care:                (leave blank if no)

Phone: (                 )                 -          H                           Is child Hispanic/Latino?
      (              )             -                W                                 No, not Hispanic/Latino               Yes, Hispanic Latino
      (              )             -                Cell                          Determination was made by:                Parent      Observer
Email:                                                                            Race:       W      B      A               I      H
                                                                                  Determination was made by:                Parent      Observer

Lives with 1:                      ,                                                    Lives with 2:           ,
           Last Name / First Name                                                                  Last Name / First Name
Relationship:                                                                           Relationship:
Address:                                                                                Address:
      ,                                                                                       ,
City / State / Zip                                                                      City / State / Zip
Others in home:                                Relationship:         Age:




Primary Medical Provider:                                                                                Clinic Name:
Address:                                                                                                 Phone: (     )             -
     ,                                                                                                   Fax: (     )          -
City / State / Zip                                                                                       Email:

Agencies/Programs Involved
            Name                                                        Address                         Contact Person                               Phone
                                                                                                                                (           )           -
                                                                                                                                (           )           -
                                                                                                                                (           )           -
                                                                                                                                (           )           -
                                                                                                                                (           )           -

Medicaid:                    Yes                 No                           hawk-i:             Yes          No
Number (if known):
Waiver:              Yes                       No                             Private Health Insurance:                  Yes                No
Type:                                                                         Name:



                                                    Initial IFSP meeting:     /           /              Periodic Review due:                    /             /
OFFICIAL REMINDERS
                                                    Annual Review due:       /           /               Child turns 3 on:              /            /


Race Codes: W = White; B = Black or African American; A = Asian; I = American Indian or Alaska
Native; H = Native Hawaiian or Other Pacific Islander




                                                                                    1                                                                     Updated 1-21-2009
                                                                                                                                                              August 2008
Child Name:                                                             DOB:         /   /                  Meeting Date:        /     /



                                                                 IFSP Meeting Details


Meeting Type:           Initial        Periodic          Annual             Is this also a Transition Planning Meeting?              Yes          No

45-day timeline met for Initial IFSP Meeting?                   Yes          No

Reason if not met:           Family             Agency          Other         Describe other reason:


  Periodic Review Method                        Meeting           Conference call                  Other means (describe):

  Written Meeting Notice                Date sent:          /           /                    By:


                                  Meeting Participants (includes all Periodic Review Methods)
                                                                                                                     Method of Participation
                  Name                                    Role                                Agency                 (e.g. meeting, conf. call, records
                                                                                                                                available)
                                                Service Coordinator
                                                Parent




Eligibility (for Initial IFSP only)

Is Child Eligible?          Yes            No
   Basis for Eligibility:             Known condition / High probability / Informed Clinical Opinion (HP)
                                      25% or greater developmental delay (TD)

Overall Primary Setting (IT Code) (select one only for each IFSP)

         IT1 Program designed for children with developmental delay/disability
         IT2 Program designed for typically developing children
         IT3 Home
         IT4 Hospital (Inpatient)
         IT5 Residential Facility
         IT6 Service Provider Location
         IT7 Other Setting

     Notes:

Parental Rights Given & Explained Annually                      Date:            /       /            By whom:




                                                                             2                                                             August 2008
Child Name:                                         DOB:    /    /               Current Date:   /      /



                                                                Family Statements


   Family declines family assessment at this time
                                                               Family Statements
          Family Areas
                                                     (Information about our child and family)
Child and Family Strengths
Things my child does well. What
pleases us most about our child. What
things are going well for our child and
family right now. The people, places,
and activities our family enjoys.



Family Concerns
Concerns I have about my child’s
health and development. Information,
resources, support I need or want for
my child and/or family.




Family Resources

Resources that my child/family has for
support, including people, activities,
programs/organizations.
Include transportation.




Family Priorities/Outcomes

My hopes and dreams for my child.
The most important things for my child
and/or family right now. My top
priorities/outcomes for my child and/or
family during the next year.


Other Information (optional)

Additional information I would like the
IFSP team members to know about my
child and/or family. Routines we
participate in or would like to do.
Special conditions facing my family.




                                                       3                                             August 2008
Child Name:                                                        DOB:       /    /                   Current Date:         /    /




                                                                         IFSP Evaluations and Assessments


   Interim             Initial           Periodic            Annual
Physical—                  The ability to demonstrate strength and coordination of large muscles such as arms, leg, or foot muscles
                           or the entire body (e.g. rolling over, sitting, crawling, walking, running).
 Gross Motor
Method*: R:                                                                 By:                             Discipline:
         I:
         O:
         T:
Date:       /      /       Location:         home              agency                clinic          other:
Present level of development (include current age, adjusted age, developmental age, percent delay, strengths, unique needs, etc):



Recommendations:



Physical—                          The ability to demonstrate strength and coordination of small muscles (e.g. picking up small objects,
                                   transfer small objects from hand to hand).
 Fine Motor
Method*: R:                                                                By:                                  Discipline:
         I:
         O:
         T:
Date:       /      /               Location:          home           agency            clinic           other:
Present level of development (include current age, adjusted age, developmental age, percent delay, strengths, unique needs, etc):



Recommendations:



Cognitive                                 The ability to solve problems, play, understand, remember, perceive, and make sense out of
                                          experiences and information.

Method*: R:                                                             By:                              Discipline:
         I:
         O:
         T:
Date:       /      /               Location:         home           agency            clinic           other:
Present level of development (include current age, adjusted age, developmental age, percent delay, strengths, unique needs, etc):


Recommendations:

*Method: R – Record Reviews;     I – Interviews;   O – Observations;   T – Tests/Assessments




                                                                         4                                                             August 2008
Child Name:                                                         DOB:         /    /                        Current Date:          /     /



                                                                           IFSP Evaluations and Assessments


Communication                   The ability to express wants, ideas, and opinions through gestures, vocalization, signs, and/or words.
                                The ability to understand language and emotions and the ability to follow directions.

Method*: R:                                                          By:                               Discipline:
         I:
         O:
         T:
Date:       /      /       Location:         home            agency           clinic          other:
Present level of development (include current age, adjusted age, developmental age, percent delay, strengths, unique needs, etc):


Recommendations:




Social/Emotional                The ability to relate to others, participate in routine activities, and demonstrate self-control.

Method*: R:                                                             By:                                  Discipline:
         I:
         O:
         T:
Date:       /      /       Location:         home            agency           clinic          other:
Present level of development (include current age, adjusted age, developmental age, percent delay, strengths, unique needs, etc):


Recommendations:



Adaptive                        The ability to develop and exhibit age appropriate self-help skills, including but not limited to feeding, toileting,
                                personal hygiene, dressing, and play skills

Method*: R:                                                             By:                                  Discipline:
         I:
         O:
         T:
Date:       /      /       Location:         home            agency           clinic          other:
Present level of development (include current age, adjusted age, developmental age, percent delay, strengths, unique needs, etc):


Recommendations:

*Method: R – Record Reviews;    I – Interviews;   O – Observations;     T – Tests/Assessments




                                                                           5                                                                    August 2008
Child Name:                                                   DOB:   /   /       Current Date:   /   /



                                                                 IFSP Evaluations and Assessments



Current Health Status

Date:            /     /            Sources of information:

Diagnoses:
          NA

Medications:
          None

Allergies:
          No known allergies

Medical/Safety Alert:
          None

Immunizations:             Up to date     Needed (list):
Vision:


Hearing:


Nutrition:

PEACH score:
Overall current health status:

Additional Information/Evaluations:




                                                                 6                                       August 2008
Child Name:                                   DOB:    /   /             Current Date:   /   /




                                                              IFSP Outcomes

    Interim             Initial   Periodic   Annual
    Transition-related

Outcome #
Outcome expected based on
family priorities.

Criteria
Observable/measurable
action or behavior to show
that progress is being made.

Timeline
How many months to
achieve or date of estimated
completion.
Procedures and
Activities
Used to determine degree of
progress and if modifications
are necessary (e.g.
observation, functional
assessment, video tape,
progress monitoring).
Progress Notes
Progress made toward
achieving the desired
Outcome.

Outcome #
Outcome expected based on
family priorities.

Criteria
Observable/measurable
action or behavior to show
that progress is being made.

Timeline
How many months to
achieve or date of estimated
completion.
Procedures and
Activities
Used to determine degree of
progress and if modifications
are necessary (e.g.
observation, functional
assessment, video tape,
progress monitoring).
Progress Notes
Progress made toward
achieving the desired
Outcome




                                                      7                                         August 2008
Child Name:                                   DOB:    /   /             Current Date:   /   /




                                                              IFSP Outcomes

    Interim             Initial   Periodic   Annual
    Transition-related

Outcome #
Outcome expected based on
family priorities.

Criteria
Observable/measurable
action or behavior to show
that progress is being made.

Timeline
How many months to
achieve or date of estimated
completion.
Procedures and
Activities
Used to determine degree of
progress and if modifications
are necessary (e.g.
observation, functional
assessment, video tape,
progress monitoring).
Progress Notes
Progress made toward
achieving the desired
Outcome.

Outcome #
Outcome expected based on
family priorities.

Criteria
Observable/measurable
action or behavior to show
that progress is being made.

Timeline
How many months to
achieve or date of estimated
completion.
Procedures and
Activities
Used to determine degree of
progress and if modifications
are necessary (e.g.
observation, functional
assessment, video tape,
progress monitoring).
Progress Notes
Progress made toward
achieving the desired
Outcome




                                                      8                                         August 2008
Child Name:                                   DOB:    /   /             Current Date:   /   /




                                                              IFSP Outcomes

    Interim             Initial   Periodic   Annual
    Transition-related

Outcome #
Outcome expected based on
family priorities.

Criteria
Observable/measurable
action or behavior to show
that progress is being made.

Timeline
How many months to
achieve or date of estimated
completion.
Procedures and
Activities
Used to determine degree of
progress and if modifications
are necessary (e.g.
observation, functional
assessment, video tape,
progress monitoring).
Progress Notes
Progress made toward
achieving the desired
Outcome.

Outcome #
Outcome expected based on
family priorities.

Criteria
Observable/measurable
action or behavior to show
that progress is being made.

Timeline
How many months to
achieve or date of estimated
completion.
Procedures and
Activities
Used to determine degree of
progress and if modifications
are necessary (e.g.
observation, functional
assessment, video tape,
progress monitoring).
Progress Notes
Progress made toward
achieving the desired
Outcome




                                                      9                                         August 2008
Child Name:                                                         DOB:        /    /                    Current Date:         /    /

                                                                  IFSP Early Intervention Services

   Interim             Initial           Periodic            Annual                                                Change in Service Provider
Service: Service Coordination
 Provider:                                                               Agency:
 Discipline:                                                             Phone: (          )       -
 Location where service provided:                                        Justification if not Natural Environment:
 Method:        Individual    Group                                      With whom:          Child    Child/Adult            Family/Caregiver
 Frequency:                                                              Intensity:
 Start Date:       /       /                                             Expected Duration:            months
  If service not initiated within 30 days of IFSP meeting date, indicate reason:
      Family (FA)        Agency/System (AG)        Outside/Other (OU)         NA
  Discontinue / Change Date:                /        /                   Discontinue / Change Reason*:               MGS         PDS           MAK
                                                                                                                    CAD         CRD           CRI

Service:
 Provider:                                                               Agency:
 Discipline:                                                             Phone: (          )       -
 Location where service provided:                                        Justification if not Natural Environment:
 Method:       Individual      Group                                     With whom:          Child       Child/Adult          Family/Caregiver
 Frequency: (how often)      sessions per                                Intensity: (minutes per session)
 Start Date:       /      /                                              Expected Duration:              months
  If service not initiated within 30 days of IFSP meeting date, indicate reason:
      Family (FA)        Agency/System (AG)        Outside/Other (OU)         NA
  Discontinue / Change Date:                /        /                   Discontinue / Change Reason*:               MGS         PDS           MAK
                                                                                                                    CAD         CRD           CRI

Service:
 Provider:                                                               Agency:
 Discipline:                                                             Phone: (          )       -
 Location where service provided:                                        Justification if not Natural Environment:
 Method:       Individual      Group                                     With whom:          Child      Child/Adult          Family/Caregiver
 Frequency: (how often)      sessions per                                Intensity: (minutes per session)
 Start Date:       /      /                                              Expected Duration:               months
  If service not initiated within 30 days of IFSP meeting date, indicate reason:
      Family (FA)        Agency/System (AG)        Outside/Other (OU)         NA
  Discontinue / Change Date:                /        /                   Discontinue / Change Reason*:               MGS         PDS           MAK
                                                                                                                    CAD         CRD           CRI

Service:
 Provider:                                                               Agency:
 Discipline:                                                             Phone: (          )       -
 Location where service provided:                                        Justification if not Natural Environment:
 Method:     Individual     Group                                        With whom:          Child        Child/Adult         Family/Caregiver
 Frequency: (how often)      sessions per                                Intensity: (minutes per session)
 Start Date:       /     /                                               Expected Duration:              months
  If service not initiated within 30 days of IFSP meeting date, indicate reason:
      Family (FA)        Agency/System (AG)        Outside/Other (OU)         NA
  Discontinue / Change Date:                /        /                   Discontinue / Change Reason*:               MGS         PDS           MAK
                                                                                                                    CAD         CRD           CRI
*MGS Met outcome, outcome not appropriate, or this service no longer needed, still receiving other EI services, continuing IFSP.
 PDS One or more service(s) discontinued at parent request, continuing IFSP.
 MAK Moved residence to another AEA, known to be continuing IFSP.
 CAD Change in attending district within AEA boundaries, outside AEA boundaries, or outside state; continuing IFSP, no change in residence.
 CRD Change in resident district within same AEA, continuing IFSP.
 CRI Change in roster information, continuing Iowa IFSP in same district.


                                                                         10                                                         Updated 2-11-2009
                                                                                                                                        August 2008
Child Name:                                                         DOB:        /    /                    Current Date:         /    /

                                                                  IFSP Early Intervention Services

   Interim             Initial           Periodic            Annual                                                Change in Service Provider
Service:
 Provider:                                                               Agency:
 Discipline:                                                             Phone: (          )       -
 Location where service provided:                                        Justification if not Natural Environment:
 Method:       Individual      Group                                     With whom:          Child       Child/Adult          Family/Caregiver
 Frequency: (how often)      sessions per                                Intensity: (minutes per session)
 Start Date:       /      /                                              Expected Duration:              months
  If service not initiated within 30 days of IFSP meeting date, indicate reason:
      Family (FA)        Agency/System (AG)        Outside/Other (OU)         NA
  Discontinue / Change Date:                /        /                   Discontinue / Change Reason*:               MGS         PDS           MAK
                                                                                                                    CAD         CRD           CRI

Service:
 Provider:                                                               Agency:
 Discipline:                                                             Phone: (          )       -
 Location where service provided:                                        Justification if not Natural Environment:
 Method:       Individual      Group                                     With whom:          Child      Child/Adult          Family/Caregiver
 Frequency: (how often)      sessions per                                Intensity: (minutes per session)
 Start Date:       /      /                                              Expected Duration:               months
  If service not initiated within 30 days of IFSP meeting date, indicate reason:
      Family (FA)        Agency/System (AG)        Outside/Other (OU)         NA
  Discontinue / Change Date:                /        /                   Discontinue / Change Reason*:               MGS         PDS           MAK
                                                                                                                    CAD         CRD           CRI

Service:
 Provider:                                                               Agency:
 Discipline:                                                             Phone: (          )       -
 Location where service provided:                                        Justification if not Natural Environment:
 Method:     Individual     Group                                        With whom:          Child        Child/Adult         Family/Caregiver
 Frequency: (how often)      sessions per                                Intensity: (minutes per session)
 Start Date:       /     /                                               Expected Duration:              months
  If service not initiated within 30 days of IFSP meeting date, indicate reason:
      Family (FA)        Agency/System (AG)        Outside/Other (OU)         NA
  Discontinue / Change Date:                /        /                   Discontinue / Change Reason*:               MGS         PDS           MAK
                                                                                                                    CAD         CRD           CRI

Service:
 Provider:                                                               Agency:
 Discipline:                                                             Phone: (          )       -
 Location where service provided:                                        Justification if not Natural Environment:
 Method:       Individual      Group                                     With whom:          Child      Child/Adult          Family/Caregiver
 Frequency: (how often)      sessions per                                Intensity: (minutes per session)
 Start Date:       /      /                                              Expected Duration:               months
  If service not initiated within 30 days of IFSP meeting date, indicate reason:
      Family (FA)        Agency/System (AG)        Outside/Other (OU)         NA
  Discontinue / Change Date:                /        /                   Discontinue / Change Reason*:               MGS         PDS           MAK
                                                                                                                    CAD         CRD           CRI
*MGS Met IFSP outcome or outcome not appropriate, continuing IFSP.
 PDS One or more service(s) discontinued at parent request, continuing IFSP.
 MAK Moved residence to another AEA, known to be continuing IFSP.
 CAD Change in attending district within AEA boundaries, outside AEA boundaries, or outside state; continuing IFSP, no change in residence.
 CRD Change in resident district within same AEA, continuing IFSP.
 CRI Change in roster information.


                                                                         11                                                         Updated 2-11-2009
                                                                                                                                        August 2008
Child Name:                                                   DOB:        /   /                      Current Date:     /   /




                                                         IFSP Other Services
                                                     (non-EA services related to Outcomes)

  Interim             Initial        Periodic        Annual


Service:
 Provider Type:           CHSC      Hospital–based       Clinic/Private           Public Health Agency        Other:
 Name:                                                        Agency Name:
 Address:                                                     City/State/Zip             ,
 Phone: (         )         -                                 Email:
 Start Date:          /         /                             End Date:              /           /
NOTES:


Service:
 Provider Type:           CHSC      Hospital–based       Clinic/Private           Public Health Agency        Other:
 Name:                                                        Agency Name:
 Address:                                                     City/State/Zip             ,
 Phone: (         )         -                                 Email:
 Start Date:          /         /                             End Date:              /       /
NOTES:


Service:
 Provider Type:           CHSC      Hospital–based       Clinic/Private           Public Health Agency        Other:
 Name:                                                        Agency Name:
 Address:                                                     City/State/Zip             ,
 Phone: (         )         -                                 Email:
 Start Date:          /         /                             End Date:              /           /
NOTES:


Service:
 Provider Type:           CHSC      Hospital–based       Clinic/Private           Public Health Agency        Other:
 Name:                                                        Agency Name:
 Address:                                                     City/State/Zip             ,
 Phone: (         )         -                                 Email:
 Start Date:          /         /                             End Date:              /           /
NOTES:



                                                               12                                                          August 2008
Child Name:                                                    DOB:       /   /                      Current Date:         /     /




                                                   Early Childhood Outcomes (ECO) 1/3


ECO based on IFSP dated:                /      /                                  Initial IFSP        Annual IFSP             Exit from Part C

1. Positive Social-Emotional Skills (including social relationships):
   a. Comparison to peers or standards: To what extent does this child show age-appropriate functioning in the area
       of positive social-emotional skills across a variety of settings and situations?
Check 0ne
                                                                                   Age Appropriate
  Child’s     Outcom
  Rating      e Rating                                   Outcome Rating Definitions and Descriptions:
                                                        Functioning expected for his or her age in all or almost all of everyday situations that
                                                         are part of the child’s life
                 7        Completely means:
                                                        Functioning is considered appropriate for his or her age
                                                        No concerns about functioning
                          Between Completely
                                                        Functioning generally is considered appropriate for his or her age
                 6        and Somewhat
                          means:                        Some concerns about functioning

                                                              Below Age Appropriate
                                                        Functioning expected for his or her age some of the time and/or in some situations
                 5        Somewhat means:               Functioning is a mix of age appropriate and not age appropriate
                                                        Functioning might be described as like that of a slightly younger child
                          Between Somewhat
                 4        and Emerging                  Functioning rarely shows the use of age appropriate skills and behaviors
                          means:
                                                        Does not yet show functioning expected of a child of his or her age in any situation
                                                        Skills and behaviors include immediate foundational skills upon which to build age
                 3        Emerging means:
                                                         appropriate functioning
                                                        Functioning might be described as like that of a younger child
                          Between Emerging
                 2                                      Uses some immediate foundational skills across settings and situations
                          and Not Yet means:
                                                        Does not yet show functioning expected of a child his or her age in any situation
                                                        Skills and behaviors do not yet include any immediate foundational skills upon
                 1        Not Yet means:
                                                         which to build age appropriate functioning
                                                        Functioning might be described as like that of a much younger child

   b. Progress: Has the child shown any new skills or behaviors related to positive social-emotional skills since the last
       IFSP meeting?     Yes      No     Not Applicable because this is the child’s Initial IFSP Meeting

   c. Supporting Evidence for Outcome Rating and Progress Positive Social-Emotional Skills:
                                                                                                                     Summary of Relevant
      Date of               Method used                            Sources of Information                                    Results
    Assessment           (Check all that apply)                   (Describe for each check)                          (Include present level of
                                                                                                                           performance)
      /     /             Record Review

      /     /              Interviews

      /     /              Observations

      /     /             Tests/Assessments




                                                                   13                                                                August 2008
Child Name:                                                    DOB:       /   /                      Current Date:         /    /




                                                   Early Childhood Outcomes (ECO) 2/3


2. Acquisition and Use of Knowledge & Skills (including early language/communication):

  a. Comparison to peers or standards: To what extent does this child show age-appropriate functioning in the area
     of acquisition and use of knowledge and skills across a variety of settings and situations?
Check 0ne
                                                            Age Appropriate
  Child’s       Outcome
  Rating         Rating                                       Outcome Rating Definitions and Descriptions:
                                                        Functioning expected for his or her age in all or almost all of everyday situations that
                                                         are part of the child’s life
                  7          Completely means:
                                                        Functioning is considered appropriate for his or her age
                                                        No concerns about functioning
                             Between Completely
                                                        Functioning generally is considered appropriate for his or her age
                  6          and Somewhat
                             means:                     Some concerns about functioning

                                                         Below Age Appropriate
                                                        Functioning expected for his or her age some of the time and/or in some situations
                  5          Somewhat means:            Functioning is a mix of age appropriate and not age appropriate
                                                        Functioning might be described as like that of a slightly younger child
                             Between Somewhat
                  4                                     Functioning rarely shows the use of age appropriate skills and behaviors
                             and Emerging means:
                                                        Does not yet show functioning expected of a child of his or her age in any situation
                                                        Skills and behaviors include immediate foundational skills upon which to build age
                  3          Emerging means:
                                                         appropriate functioning
                                                        Functioning might be described as like that of a younger child
                             Between Emerging
                  2                                     Uses some immediate foundational skills across settings and situations
                             and Not Yet means:
                                                        Does not yet show functioning expected of a child his or her age in any situation
                                                        Skills and behaviors do not yet include any immediate foundational skills upon
                  1          Not Yet means:
                                                         which to build age appropriate functioning
                                                        Functioning might be described as like that of a much younger child

 b. Progress: Has the child shown any new skills or behaviors related to acquisition and use of knowledge and skills
    since the last IFSP meeting?  Yes       No         Not Applicable because this is the child’s Initial IFSP Meeting

 c. Supporting Evidence for Outcome Rating and Progress in Acquisition and Use of Knowledge and Skills:

                                                                   Sources of Information                            Summary of Relevant
     Date of                 Method used                          (Describe for each check)                                  Results
   Assessment             (Check all that apply)                                                                     (Include present level of
                                                                                                                           performance)
     /      /               Record Review

     /      /               Interviews

     /      /              Observations

     /      /              Tests/Assessments




                                                                   14                                                               August 2008
Child Name:                                                    DOB:          /     /                         Current Date:               /     /




                                                 Early Childhood Outcomes (ECO) 3/3


3. Use of Appropriate Behaviors to Meet Their Needs:

  a. Comparison to peers or standards: To what extent does this child show age-appropriate functioning in the area of
      use of appropriate behaviors to meet his or her needs across a variety of settings and situations?
Check 0ne
                                                        Age Appropriate
 Child’s        Outcome
 Rating          Rating                                Outcome Rating Definitions and Descriptions:
                                                      Functioning expected for his or her age in all or almost all of everyday situations that are part of the
                                                       child’s life
                   7       Completely means:
                                                      Functioning is considered appropriate for his or her age
                                                      No concerns about functioning
                           Between Completely
                                                      Functioning generally is considered appropriate for his or her age
                   6       and Somewhat
                           means:                     Some concerns about functioning

                                                           Below Age Appropriate
                                                      Functioning expected for his or her age some of the time and/or in some situations
                   5       Somewhat means:            Functioning is a mix of age appropriate and not age appropriate
                                                      Functioning might be described as like that of a slightly younger child
                           Between Somewhat
                   4                                  Functioning rarely shows the use of age appropriate skills and behaviors
                           and Emerging means:
                                                      Does not yet show functioning expected of a child of his or her age in any situation
                                                      Skills and behaviors include immediate foundational skills upon which to build age appropriate
                   3       Emerging means:
                                                       functioning
                                                      Functioning might be described as like that of a younger child
                           Between Emerging
                   2                                  Uses some immediate foundational skills across settings and situations
                           and Not Yet means:
                                                      Does not yet show functioning expected of a child his or her age in any situation
                                                      Skills and behaviors do not yet include any immediate foundational skills upon which to build age
                   1       Not Yet means:
                                                       appropriate functioning
                                                      Functioning might be described as like that of a much younger child

b. Progress: Has the child shown any new skills or behaviors related to the use of appropriate behaviors to meet his/her
    needs since the last IFSP meeting?  Yes        No     Not Applicable because this is the child’s Initial IFSP
                                                          Meeting

c. Supporting Evidence for Outcome Rating and Progress in Use of Appropriate Behaviors to Meet Their Needs:

                                                                                                                                Summary of Relevant
     Date of             Method(s) used                            Sources of Information                                               Results
   Assessment          (Check all that apply)                     (Describe for each check)                                     (Include present level of
                                                                                                                                      performance)
     /      /             Record Review

     /      /             Interviews

     /      /             Observations

     /      /             Tests/Assessments




                                                                   15                                                                               August 2008
Child Name:                                                                DOB:        /    /                     Plan Initiation Date:
                                                                                                                        /        /


                                                                                      IFSP Transition Plan


   Projected Transition Planning Dates                                                      Part B Consideration
           rd
Date of 3 birthday:             /             /                       Child will be referred for Part B eligibility determination
9 months prior:       /                 /                             Date AEA notified:         /      /
6 months prior:       /                 /                             Parent declined consideration for Part B eligibility determination
90 days prior:      /               /                                  Not applicable (Data indicate child not potentially Part B eligible)

                                                  Transition Planning Requirements and Activities
      Requirement                                                                Activities
Child’s needs,                          e.g. Assess child’s needs and options.
strengths, and abilities



                                        Person Responsible:                                                             Date Completed:    /       /
Family involvement                      e.g. Explain transition, discuss program options, check out options, parental rights




                                        Person Responsible:                                                             Date Completed:    /       /
Strategies to prepare                   e.g. Ways to help child prepare and adjust to new setting
child


                                        Person Responsible:                                                             Date Completed:    /       /

Transition Planning                     e.g. Meeting planned; attempts to engage family in a meeting
Meeting


                                        Person Responsible:                                                             Date Completed:    /       /

Sharing information                     e.g. Transfer of info to other program
about child

                                            NA—Authorization already in place or not needed
                                        Person Responsible:                                                             Date Completed:    /       /
Plans for services
(other than Part B
services) to be
provided following the
child’s third birthday?                     NA—Child transitioning to Part B services or no other services to be provided
Scheduling of Initial IEP
meeting
                                            NA—Child not transitioning to Part B services
Part B services to be
provided following the
child’s third birthday                      NA—Child not transitioning to Part B services

                                                                                                EFB          EOP          ENR        BND         DEC
FINAL EXIT DATE                 /             /             FINAL EXIT REASON*
                                                                                                PMA          SDP          CMK        CMN         UNK
*EFB=eligible for Part B; EOP=exit to other program; ENR=exit no referral; BND=eligibility for Part B not determined; DEC=deceased; PMA=completion
of IFSP prior to reaching maximum age; SDP=all services discontinued at parent request ; CMK=moved out of state & continuing Part C; CMN=moved
out of state & not known if continuing Part C; UNK=unknown

                                                                                 16                                                            August 2008

								
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