INDIVIDUALIZED FAMILY SERVICE PLAN
NAME:
DATE OF BIRTH:
AGE IN MONTHS:
CASE #:
____/____/______
______
_______________
ADDRESS:
LANGUAGE(S) CHILD HEARS MOST OF THE DAY:
PRIMARY PARENT/GUARDIAN NAME:
RELATIONSHIP TO CHILD:
ADDRESS:
PHONE (HOME):
PHONE (CELL):
LANGUAGE(S) SPOKEN/MODE OF COMMUNICATION:
OTHER PARENT/GUARDIAN NAME:
RELATIONSHIP TO CHILD:
ADDRESS:
PHONE (HOME):
PHONE (CELL):
LANGUAGE(S) SPOKEN/MODE OF COMMUNICATION:
MEETING INFORMATION:
Interim Initial 6 month Amendment Transition
PROJECTED REVIEW DATE:
____/____/______
IFSP TEAM MEMBERS ATTENDANCE
Please note that your signature reflects your participation at the conference and does not necessarily indicate
agreement or disagreement with the Individualized Education Program.
SPECIALTY / RELATIONSHIP
MEMBER'S NAME
SIGNATURE
TO CHILD
Primary parent / guardian
Other parent / guardian
Service coordinator
I received a copy of the early intervention procedural safeguards and due process procedures and an explanation
of this information.
I understand the procedural safeguards and due process procedures.
I participated in the review/change of the IFSP with the EDIS team.
I am in agreement with this review/change to the IFSP.
PRIMARY PARENT / GUARDIAN SIGNATURE
OTHER PARENT / GUARDIAN SIGNATURE
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NAME:
EI #:
_______________
AGE:
_______
DOB:
____/____/______
Conference date:
____/____/______
Present levels of performance
Communication: How your child understands and lets you know what he or she wants or needs.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Social/Emotional: How your child gets along with family members and other people.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Cognitive: How your child understands concepts and solves problems.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Adaptive: How your child performs tasks such as eating, dressing, bathing, toileting and sleeping.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Motor: How your child moves and uses his / her hands.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Family concerns and resources:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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NAME:
EI #:
_______________
AGE:
_______
DOB:
____/____/______
Conference date:
____/____/______
Outcome
OUTCOME:
SHORT TERM GOALS THAT SHOULD BE ACHIEVED IN ORDER FOR THE CHILD TO REACH THE
OUTCOME:
DESCRIBE WHAT CONSTITUTES PROGRESS TOWARD ACHIEVING THE DESIREDOUTCOME AND HOW
PROGRESS WILL BE MEASURED (I.E. OBSERVATION; PARENT REPORT; ONGOING ASSESSMENT; ETC.)
OUTCOME:
SHORT TERM GOALS THAT SHOULD BE ACHIEVED IN ORDER FOR THE CHILD TO REACH THE
OUTCOME:
DESCRIBE WHAT CONSTITUTES PROGRESS TOWARD ACHIEVING THE DESIREDOUTCOME AND HOW
PROGRESS WILL BE MEASURED (I.E. OBSERVATION; PARENT REPORT; ONGOING ASSESSMENT; ETC.)
OUTCOME:
SHORT TERM GOALS THAT SHOULD BE ACHIEVED IN ORDER FOR THE CHILD TO REACH THE
OUTCOME:
DESCRIBE WHAT CONSTITUTES PROGRESS TOWARD ACHIEVING THE DESIREDOUTCOME AND HOW
PROGRESS WILL BE MEASURED (I.E. OBSERVATION; PARENT REPORT; ONGOING ASSESSMENT; ETC.)
OUTCOME:
SHORT TERM GOALS THAT SHOULD BE ACHIEVED IN ORDER FOR THE CHILD TO REACH THE
OUTCOME:
DESCRIBE WHAT CONSTITUTES PROGRESS TOWARD ACHIEVING THE DESIREDOUTCOME AND HOW
PROGRESS WILL BE MEASURED (I.E. OBSERVATION; PARENT REPORT; ONGOING ASSESSMENT; ETC.)
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NAME:
EI #:
_______________
AGE:
_______
DOB:
____/____/______
Conference date:
____/____/______
Services
SERVICE
LOCATION:
SERVICE
LOCATION:
SERVICE
LOCATION:
SERVICE
LOCATION:
SERVICE
LOCATION:
SERVICE
LOCATION:
PROVIDED BY (DISCIPLINE)
DURATION
(minutes):
FREQUENCY:
START DATE:
END DATE:
____/____/______
____/____/______
PROVIDED BY (DISCIPLINE)
TYPE:*
DURATION
(minutes):
FREQUENCY:
START DATE:
END DATE:
____/____/______
____/____/______
PROVIDED BY (DISCIPLINE)
TYPE:*
DURATION
(minutes):
FREQUENCY:
START DATE:
END DATE:
____/____/______
____/____/______
PROVIDED BY (DISCIPLINE)
TYPE:*
DURATION
(minutes):
FREQUENCY:
START DATE:
END DATE:
____/____/______
____/____/______
PROVIDED BY (DISCIPLINE)
TYPE:*
DURATION
(minutes):
FREQUENCY:
START DATE:
END DATE:
____/____/______
____/____/______
PROVIDED BY (DISCIPLINE)
TYPE:*
DURATION
(minutes):
FREQUENCY:
START DATE:
END DATE:
TYPE:*
____/____/______
____/____/______
MINIMUM #
SESSIONS.
GROUP SIZE:**
MINIMUM #
SESSIONS.
GROUP SIZE:**
MINIMUM #
SESSIONS.
GROUP SIZE:**
MINIMUM #
SESSIONS.
GROUP SIZE:**
MINIMUM #
SESSIONS.
GROUP SIZE:**
MINIMUM #
SESSIONS.
GROUP SIZE:**
* Indicate type of service Individual Group Consultation Monitor **Only if service is provided in group setting
If any services provided in group settings without typically developing peers, explain why the IFSP team thinks this is appropriate:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
If assistive technology device(s) are required, describe assistive technology device and purpose:
DEVICE:
PURPOSE:
COST:
DEVICE:
STAR DATE: ____/____/______ END DATE: ____/____/______
PURPOSE:
VENDOR
COST:
STAR DATE: ____/____/______ END DATE: ____/____/______
PURPOSE:
VENDOR
STAR DATE: ____/____/______ END DATE: ____/____/______
PURPOSE:
VENDOR
STAR DATE: ____/____/______ END DATE: ____/____/______
PURPOSE:
VENDOR
DEVICE:
COST:
STAR DATE: ____/____/______
VENDOR
DEVICE:
COST:
DEVICE:
COST:
END DATE: ____/____/______
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