Part II: Child’s Developmental Status and Family Information



Child’s Name: Date:

Part II: Child’s Developmental Status and Family Information

Section A. Child’s Present Levels of Development

A. Child’s Present Levels of Development

|Area |Date |Chronological |Age Level/ |Qualitative Description |

| |M/D/Y |Age |Age Range | |

|Cognitive | | | | |

|Communication | | | | |

|Social Emotional | | | | |

|Adaptive | | | | |

|Gross Motor | | | | |

|Fine Motor | | | | |

| | | | | |

|Hearing | | | |

|Vision | | | |

|Health | | | |

Primary Health Care Provider:_______________________________________Phone: ( )_______________________

Immunizations Received: ( DTaP/DT ( IPV ( Hib ( MMR ( HepB ( Varicella

Immunizations Needed: ( DTaP/DT ( IPV ( Hib ( MMR ( HepB ( Varicella

Comments:________________________________________________________________________________________ __ _

8/2003 White: Early Intervention Record / Yellow: Parent(s) / Pink: Data Entry

Child’s Name: Date:

Part II: Child’s Developmental Status and Family Information

Section B. Child’s Strengths and Needs

Describe the strengths and needs of the child based on information obtained from the evaluation and assessment and interview(s) with the family. They may be recorded in narrative or list form.

|Strengths |Needs |

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Part II: Child’s Developmental Status and Family Information

Section C. Family Concerns, Priorities, and Resources

Record the family’s description of its concerns, priorities, and resources related to enhancing the development of the child.

The family’s concerns, priorities, and resources are to be used as the basis for developing outcomes and identifying strategies and activities to address the child’s identified needs.

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❑ This information was gathered as a result of a family-directed assessment.

❑ Family declined

8/2003 White: Early Intervention Record / Yellow: Parent(s) / Pink: Data Entry

Child’s Name: Date:

Part II: Child’s Developmental Status and Family Information

Section D. Natural Environments

To the maximum extent appropriate to the needs of the child, early intervention services are provided in natural environments, including the home and community settings in which children without disabilities participate; and the provision of early intervention services for children occurs in a setting other than the natural environment only when early intervention cannot be achieved satisfactorily for the child in a natural environment. 34CFR303.12(b). 34CFR303.167(c).

What are the settings in which the child currently spends time? (Check all that apply.)

( Child home

( Child care program

( Religious Setting

( Family day care

( Early Head Start

( Library

( Home of family member

( Toddler play group

( Family Support Center

( Parent’s place of employment

( Shelter

( Other

Where do other family members spend their time?

Are there other settings that the family would like to access but hasn’t been able to because of the child’s needs?

What are the daily routines of the child and family? Are there other routines the family would like to establish?

What barriers prohibit the provision of services in the child/family’s daily routines and activities?

What will need to change in order for services to be provided within the family’s routines and how will the change be accomplished?

8/2003 White: Early Intervention Record / Yellow: Parent(s) / Pink: Data Entry

Child’s Name: Date:

Part II: Child’s Developmental Status and Family Information

Section E. Eligibility Status

Check only one of the three boxes below designating the criteria under which the child’s eligibility was determined.

Then check the appropriate box(es) under the main category selected.

If a child with a diagnosed physical or mental condition also exhibits a 25% developmental delay or atypical development, the appropriate box to check is: Diagnosed Condition With High Probability of Developmental Delay

( Diagnosed Condition With High Probability of Developmental Delay

Check all that apply:

❑ Chromosomal disorders

❑ Down Syndrome

❑ Other ____________________

❑ Intraventricular hemorrhage - Grades III or IV

❑ Congenital infection – symptomatic

❑ Infants showing significant effects of maternal prenatal drug abuse, such as Fetal Alcohol Syndrome

❑ Prematurity with birth weight of less than 1200 grams

❑ Severe congenital malformations, such as meningomyelocele and congenital hydrocephalus

❑ Inborn errors of metabolism where either the diagnosis is late, there is not treatment available, or inadequate treatment, such as maple syrup urine disease, urea cycle defects, galactosemia, lysosomal storage diseases, and those carbohydrate disorders associated with CNS involvement

❑ Neurodegenerative disorders that have their onset in infancy and early childhood, such as adrenoleukodystrophy and TaySachs disease.

❑ Epilepsy, where seizures are frequent or difficult to control, or the underlying condition is associated with frequent cognitive impairment e.g., infantile spasms

❑ Severe encephalopathy resulting from insult to the brain, such as trauma, drowning, poisoning, or infection.

❑ Sensory impairments where appropriate treatment still leaves significant impairment, e.g. vision not corrected to normal for age in either eye, or mild or greater hearing loss in the best ear persistent even after appropriate treatment.

❑ The child is blind or visually impaired

❑ The child is deaf or hard of hearing.

❑ AIDS, symptomatic or known infected.

❑ Lead poisoning, with lead level of 20 ug/dL or greater.

❑ Infants affected by intrauterine drug exposure.

❑ Other _________________________

( 25% Developmental Delay

Check all that apply:

❑ cognitive

❑ communication

❑ social-emotional

❑ adaptive

❑ motor

( Atypical Development

Check all that apply:

❑ cognitive

❑ communication

❑ social-emotional

❑ adaptive

❑ motor

8/2003 White: Early Intervention Record / Yellow: Parent(s) / Pink: Data Entry

Child’s Name: Date:

Part III: Child/Family Outcomes Related to Child Development

|Outcome: What I would like to see happen for my child/family. |Outcome: What I would like to see happen for my child/family. |

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|Strategies/Activities |Strategies/Activities |

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|Criteria |Criteria |

|Timeline |Timeline |

|Person(s) Involved: |Person(s) Involved: |

|(Name, Title, Phone #) |(Name, Title, Phone #) |

|Date Achieved: |Date Achieved: |

Child’s Name: Date:

IFSP Part IV: Early Intervention Services

Section A

Complete one form for each service. If a child will receive a service in more than one Location or Basis, complete a separate form for each Location or Basis.

Type of Service: Check one service from the list below that was agreed upon to achieve the outcome(s) stated on part III

❑ Audiology

❑ Family Counseling/Training

❑ Health

❑ Medical (Diagnosis & Evaluation only)

❑ Nursing

❑ Nutrition

❑ Occupational Therapy

❑ Physical Therapy

❑ Psychological

❑ Respite Care

❑ Social Work

❑ Special Instruction

❑ Speech/Language Therapy

❑ Vision Services

❑ Other (specify _________________________)

Frequency: Circle the number of sessions.

1X 2X 3X 4X 5X 6X Other________

Circle a time period.

Weekly Monthly Yearly Only

Intensity: Circle the length of time, in minutes, that the service is provided during each session.

15 30 45 50 60 90 120 180 240 Other________________

Basis: Check the basis on which the service will be provided.

( Group ( Individual

Financial Responsibility: Check one agency or individual responsible for payment of services.

❑ Local School System

❑ Local Health Department

❑ Local Department of Social Services

❑ Parent

❑ Other (specify ___________________________)

Reimbursement Source: Select one reimbursement source only when the agency or individual designated as financially responsible intends to request payment for the service from another source.

❑ Medical Assistance

❑ Children’s Medical Services

Projected Service Initiation Date: Record the date, specifying month, day, and year on which the service is projected to begin.

__________________ ________________ ______________

Month Day Year

Projected Duration: Record the projected time period that the service will be provided. ______________ ______________

Month Year

8/2003

Location: Check one location where the service will be provided

❑ Program designed for children with delays/disabilities

o Justification for this location

❑ Program designed for typically developing children

o Child care

o Preschool program

o Early Head Start

o Other _______________

❑ Home

❑ Hospital (Inpatient)

o Justification for this location

❑ Residential Facility

o Justification for this location

❑ Service Provider Location

o Justification for this location

❑ Other Setting

o Library

o Parent’s place of employment

o Shelter

o Other _______________

Provider Agency: Record the name of the agency providing the service. Use standard text designated within each jurisdiction.

____________________________________________________

Provider Name/ Phone Number: Record the name/ phone number of the individual providing the service.

_________________________________________________________________

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Service Ending Date:

__________________ ________________ ______________

Month Day Year

Child’s Name: Date:

IFSP Part IV: Early Intervention Services

Section B

Complete one Part IVB form following completion of all Part IVA forms.

Review as part of all periodic reviews.

Judy Center

Does this plan include any services provided in a Judy Center? ( Yes ( No

Assistive Technology

Does this plan include assistive technology services or devices? ( Yes ( No

Type of assistive technology. Check all that apply.

❑ Assistance in selection, acquisition, or use of an assistive technology device

❑ Activities of Daily Living (ADL)

❑ Adaptive Computer Hardware

❑ Adaptive Computer Software

❑ Auditory Aids

❑ Augmentative and Alternative Communication Device (AAC)

❑ Environmental Control Units (ECUs)

❑ Mobility Aids

❑ Play, Recreation, and Leisure Aids

❑ Seating and Positioning

❑ Transportation/Safety Aids

❑ Vision Aids

❑ Other__________________________

Provider Name:____________________________________________Phone Number:

Provider Name:____________________________________________Phone Number:

Provider Name:____________________________________________Phone Number:

Transportation

Does this plan include transportation? ( Yes ( No

Type of transportation: ( Parent with reimbursement

( Agency bus or van

( Other____________________________

Is any special equipment needed for transporting this child? ( Yes ( No

Provider Name:_____________________________________________Phone Number:

Child’s Name: Date:

ID Number:

Part V: Service Linkages

Complete one form for each person for whom service linkages are identified.

Check one of the following:

( Eligible Child (Sibling (Family ( Parent/Guardian ( Other relative

Type of Service: Record the identified linkage service by selecting all that apply.

Child Care/Enrichment

❑ Camps, Day/Residential

❑ Family Day Care

❑ Group Child Care Centers

❑ Early Head Start/Head Start

❑ In-home Child Care

❑ Preschool Program

❑ School-age Child Care

❑ Tutoring

❑ Other______________

Counseling

❑ Adolescent

❑ Employment

❑ Family

❑ Genetic

❑ Housing

❑ Marital

❑ Special

❑ Other ____________

Income Assistance

❑ Emergency Financial Assistance

❑ Financial counseling

❑ Food Stamps

❑ Public Assistance

❑ SSI

❑ Other____________

Medical/Health

❑ Assessment

❑ Dental Services

❑ Diagnostic/Advisory Clinics

❑ Equipment/Devices

❑ Home Health Care

❑ Hospitalization

❑ Immunizations

❑ Mental Health Services

❑ Prenatal Care

❑ Prescription Drugs

❑ Primary Health Care

❑ Screening

❑ Substance Abuse Treatment

❑ Surgical Procedure

❑ WIC Program

❑ Other____________

Other

❑ Adult Education

❑ Family Support Center

❑ Family Support Network, Local

❑ Family Support Network, State

❑ Housing

❑ Legal Services

❑ Parent Education

❑ Project Independence

❑ Support Group

❑ Recreation Program

❑ Other__________

Provider Agencies: Enter the names of the agencies, organizations, programs, or individuals through which the services will be provided.

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Strategies to Secure Services: Enter identified strategies to secure the services, if needed.

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Payment Sources: Check the payment source(s) Name of Person(s) Involved:

❑ Health Maintenance Organization (HMO) Title:

❑ Medical Assistance Phone Number:

❑ No fee

❑ Other Health Insurance

❑ Parent-Full Payment

❑ Parent – Sliding Fees

❑ Other (Specify___________________)

8/2003 White: Early Intervention Record / Yellow: Parent(s) / Pink: Data Entry

Child’s Name: Date:____________________

ID Number:

Part VI: Transition Information

Section A. Part B Eligibility

IEP Eligibility Determination Meeting Date____________________

If IEP Eligibility Determination Meeting Date was not held at least 90 days before the child’s third birthday, check one or more responses that provide an explanation:

❑ Child was referred within the 90-day timeline period.

❑ Parent choice (Parent chose to reschedule or delay the meeting)

❑ Parent declined to consider eligibility in Part B (No meeting was held)

❑ Other____________________________________________

Results of the IEP Eligibility Determination Meeting: (Check one.)

( The child is determined to be eligible for preschool special education by the IEP team.

( The child is determined to be ineligible for preschool special education by the IEP team.

( Child is determined to be eligible for preschool special education but parent declined participation.

(If child will not be participating in preschool special education,

go to Section B, “Referred to Community Services”)

Check the Part B Disability Category:

❑ Autism

❑ Deaf-blindness

❑ Developmental Delay

❑ Emotional disturbance

❑ Hearing impairment, including deafness

❑ Mental retardation

❑ Multiple disability

❑ Orthopedic impairment

❑ Other health impairment

❑ Specific learning disability

❑ Speech or language impairment

❑ Traumatic brain injury

❑ Visual impairment, including blindness

If the child’s third birthday will occur after the end of one school year and before the beginning of the following school year, Was ESY considered? (Yes ( No

Will ESY be provided? ( Yes ( No

Was an IEP developed at the eligibility determination meeting? ( Yes ( No

LRE (Least Restrictive Environment) as identified on the IEP. Check one if known. (Note: Codes “E” through “L” may be used for 3-21 year olds; Codes M, N, and O apply only to preschoolers.)

❑ E Hospital Placement

❑ F Public Separate Day School

❑ G Private Separate Day School

❑ H Public Residential Facility

❑ I Private Residential Facility or Center

❑ J Home

❑ K Itinerant Setting

❑ L Reverse Mainstreaming

❑ M Early Childhood Setting

❑ N Early Childhood Special Education Setting

❑ O Part-Time Early Childhood/Part-Time Early Childhood Special Education Setting

8/2003 White: Early Intervention Record / Yellow: Parent(s) / Pink: Data Entry

Child’s Name: Date:

ID Number:

Part VI: Transition Information

Section B. Referral to Community Services

Complete this section for all children.

Referred to Community Services (check one) (Yes (No

If yes, check all that apply.

Developmental/Medical/Health

❑ Developmental Therapies (other than Part B)

❑ Equipment/Devices

❑ Home Health Care

❑ Immunizations

❑ Mental Health Services

❑ Primary Health Care

❑ WIC Program

Child Care/Enrichment

❑ Camps (Day/Residential)

❑ Family Day Care

❑ Group Child Care

❑ Even Start

❑ Head Start

❑ Play Group

❑ Preschool Program

o Private

o Public

❑ Recreation Program

❑ Judy Center

❑ HIPPY

Family Support

❑ Family Support Center

❑ Parent Education

❑ Support Group

❑ Other_________________________

Other

Transition Notes:

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8/2003 White: Early Intervention Record / Yellow: Parent(s) / Pink: Data Entry

LRE Code Definitions:

(Note: Codes “E” through “L” may be used for 3-21 year olds; Codes M, N, and O apply only to preschoolers.)

E Hospital Placement: Students receive greater than 50% of instruction in hospital.

F Public Separate Day School. Includes students who spend greater than 50% of the school day in separate public facilities as a day student.

G Private Separate Day School. Includes students who spend greater than 50% of the school day in separate private facilities as a day student.

H Public Residential Facility – Placement as a residential student

I Private Residential Facility or Center – Placement as a residential student

J Home. Includes preschoolers who receive services at home, not single service.

K Itinerant Setting – Includes preschoolers who receive only speech and/or language at school or other location.

L Reverse Mainstreaming – Includes preschoolers who receive special education in class designated for disabled student where over 50% of the students are not disabled.

M Early Childhood Setting – Includes preschoolers who receive all of their special education and related services in education programs designed primarily for children without disabilities. No education or related services are provided in separate special education settings. This may include, but is not limited to: regular kindergarten classes; public or private preschools; Head Start Centers; child care facilities; preschool classes offered to an eligible pre-kindergarten population by the public school system; home/early childhood combinations; home/Head Start combinations; and other combinations of early childhood settings.

N Early Childhood Special Education Setting – Includes preschoolers who receive all of their education and related services in educational programs designed primarily for children with disabilities housed in regular school buildings or other community-based settings. This may include, but is not limited to: special education classrooms in regular school buildings; special education classrooms in childcare facilities; hospital facilities on an outpatient basis, or other community-based settings; and special education classrooms in trailers or portables outside regular school buildings.

O Part-Time Early Childhood/Part-Time Early Childhood Special Education Setting – Includes preschoolers who receive services in multiple settings, such that: (1) general and/or special education and related services provided at home or in education programs designed primarily for children without disabilities, and (2) special education and related services are provided in programs designed primarily for children with disabilities. This may include, but is not limited to: home/early childhood special education combinations; Head Start, child care, nursery school facilities, hospital facilities on an outpatient basis, or other community-based settings with special education provided outside of the regular class; regular kindergarten classes with special education provided outside of the regular class; separate school/early childhood combinations; and residential facility/early childhood combinations.

Child’s Name: Date:

ID Number:

Individualized Family Service Plan (IFSP)

Add/Change Form

|Changes to Child and Family Information |Review of the IFSP |

|(Parent signature not required) |(Parent signature required for all reviews) |

|Child Information: | |Review Type: (Select One) |

| |Meeting Date: |

|Child’s Name: |( Six Month |

| |( Annual (Attach IFSP Cover page with signatures) |

|Address: |( Provider Request |

| |( Parent Request |

|Phone: |( Parent/Provider Request |

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|Birthdate: | |

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|Social Security #: | |

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|Medical Assistance #: | |

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|Family Information: | |

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|Name: | |

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|Address: | |

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|Phone: | |

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|Social Security #: | |

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|Relationship to Child: | |

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|Service Coordinator Information: | |

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|Name: | |

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|Agency: | |

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|Phone: | |

| |Review Status: (Select One) |

| |( Continue IFSP |

| |( Modify IFSP |

| |Service Addition |

| |Service Modification |

| |Service Ending |

| |( End IFSP (If “End IFSP” is checked, fill in Inactive Date and Reason |

| |Reasons for Inactive Status: (Select One) |

| |Inactive Date:_____________________ |

| |Attempts to contact unsuccessful |

| |Completion of IFSP prior to reaching maximum age for Part C |

| |Deceased |

| |Determined ineligible (Note: This child was never eligible.) |

| |Moved out of state |

| |Moved to another jurisdiction |

| |Name of Jurisdiction:____________________ |

| |Parent withdrawal |

| |Transition at age 3. |

I (We) have been provided with reasonable notice of the review of this IFSP. I (We) have had the opportunity to participate in the review of this IFSP. I (We) have been informed of my (our) procedural safeguards under the early intervention system and give permission to the early intervention program to implement any IFSP revisions based on this review.

Parents(s)/Guardian/Surrogate Date

Service Coordinator Date

Other Participant Agency/Title Date

Other Participant Agency/Title Date

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