Sample Individualized Family Service Plan
I. Child and Family Information
Childs Name
Date of Birth
Maria Ramirez
Parent(s)/Guardian(s) Bruce & Catherine Ramirez
Address
12-14-02
Age in Months
2120 Valley Park Place
Middletown, IN
STREET
46810
CITY
Home Telephone No. (513) 555-0330
Work Telephone No. (513) 555-1819
Preferred Language
Translator Appropriate
English
Gender F
30
Yes
ZIP CODE
No
II. Service Coordination
Coordinators Name
Address
105 Data Drive
Burlington, IN
STREET
Appointment Date
Agency Indiana Early Intervention Program
Susan Green
CITY
46980
Telephone No.
(513) 555-0214
ZIP CODE
6-10-05
III. IFSP Team Members
Name
Agency
Telephone No.
Title/Function
Susan Green
Indiana Early Intervention (EI) Program
513-555-0214
Service Coordinator
Mr. & Mrs. B. Ramirez
N/A
513-555-0330
Parents
Barbara Smith
Indiana EI Program
513-555-0215
Speech/Language Pathologist
Martha King
Indiana EI Program
513-555-0213
Occupational Therapist
Libby Young
Middletown Preschool Program
513-555-3533
Preschool Teacher
IV. Review Dates
Date of IFSP
6-10-05
Six-Month Review
12-10-05
Annual Evaluation
6-10-06
V. Statements of Family Strengths and Resources
Marias 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 familys
geographical location, limited resources are available for service delivery at this time.
(continued)
SAMPLE INDIVIDUALIZED FAMILY SERVICE PLAN
VI. Statements of Family Concerns and Priorities
CONCERNS
Due to Marias 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 Marias service delivery in her natural environment (i.e., her home) to a noninclusive center-based program.
PRIORITIES
The priorities that Marias parents have for her include improving her communication skills, her ability to use utensils,
and her toileting skills. They want services to be delivered at home with the goal of an inclusive placement with nondisabled
peers who attend a neighborhood preschool. Her parents and grandparents want to learn ways in which they can help to facilitate Marias development in her natural environment.
VII. Childs Present Level of Development and Abilities
Cognitive Skills (Thinking, reasoning, and learning)
Marias cognitive abilities are commensurate with a 20-month-old child. Shes 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 18-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; however, 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)
Marias general health is good, but she has a history of chronic otitis media and upper respiratory infections. Vision and
hearing are monitored frequently.
SAMPLE INDIVIDUALIZED FAMILY SERVICE PLAN
VIII. Outcome Statements
1. Participate in stimulation of all language modalities (visual, auditory, tactile) in order to increase communication competency.
Responsible
Begin
End
Strategies/Activities
Person/Agency Date
Date
1.1 Maria will use word approximations
SLP
6-10-05 12-10-05
combined with consistent gestures for
5 different needs across 3 different
people and 2 different settings.
1.2 Maria will use words combined with
signs for 5 different needs across
3 different people and 2 settings.
Mom and Dad
Frequency
of Service Location
Once
Home
Weekly
6-10-05 12-10-05
Evaluation Criteria
Preschool
Language Scale
Observation samples
2. Marias daily self-care skills will improve in the areas of dressing and toileting abilities.
Strategies/Activities
2.1 Maria will push down/pull up undergarments with minimal assistance.
Responsible
Begin
End
Person/Agency Date
Date
Mom and Dad
6-10-05 12-10-05
Service Coord.
Frequency
of Service Location
Once
Home
Weekly
2.2 Maria will establish a consistent
pattern of elimination.
Mom and Dad
Service Coord.
6-10-05 12-10-05 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.
6-10-05 12-10-05 Once
Weekly
Home
Observation
samples
Evaluation Criteria
Observations
3. Maria will develop improved abilities to discriminate auditory/visual stimuli.
Strategies/Activities
3.1 Indicate by pointing/verbalizing
whether objects are the same
or different.
Responsible
Begin
End
Person/Agency Date
Date
Mom and Dad
6-10-05 12-10-05
Service Coord.
Frequency
of Service Location
Once
Home
Weekly
Evaluation Criteria
Observations
3.2 Sort several colors and shapes
consistently.
Mom and Dad
Service Coord.
6-10-05 12-10-05 Once
Weekly
Home
Observation samples
3.3 Imitate words and motions in songs
upon being given a model.
Mom and Dad
Service Coord.
6-10-05 12-10-05 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
CHILDS NAME
12-14-05
PROJECTED TRANSITION DATE
1. The service coordinator will schedule meeting with parents to explain the transition process and rationale, review their
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.
SAMPLE INDIVIDUALIZED FAMILY SERVICE PLAN
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 Marias third birthday, the service coordinator will convene a meeting to further develop
Marias transition plan.
X. Identification of Natural Environments
The home environment is considered to be Marias 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) sons/daughters 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
Catherine Ramirez
SIGNATURE OF PARENT/GUARDIAN
6-10-05
DATE
NO
Bruce Ramirez
6-10-05
SIGNATURE OF PARENT/GUARDIAN
SOURCE: Adapted from R. Gargiulo and J. Kilgo, Young Children with Special Needs (2nd ed.) (Clifton Park, NY: Delmar, 2005), pp. 182185.
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