IFSP_English - RIC | RIC
4140207112000 FORMTEXT Program InformationIn Early Intervention We want children of all abilities to …Demonstrate positive emotional skills, including social relationshipsAcquire and use knowledge and skills; including early literacy skills Use appropriate behaviors to meet their needs We want all families to…Understand their children's strengths, abilities, and special needsKnow their rights and effectively communicate their children's needsHelp their children develop and learn60071014478000 My Child’s Name: __________________________________________ DOB: ______/______/______ Gender: FORMCHECKBOX Male FORMCHECKBOX Female ID#: ___________________ Referral Date: ______/_____/______Child’s Address: ______________________________________________________________________________________________________________________________________________________________1.) Parent/Guardian: ______________________________________Phone: ___________________________________________________Email: ___________________________________________________2.) Parent/Guardian: ______________________________________Phone: ___________________________________________________Email: ___________________________________________________Service Coordinator ______________________________________Phone: ______________________________ ext. ________________Email: ___________________________________________________Parent Consultant: _______________________________________Phone: _______________________________ ext. _______________Primary Care Physician: __________________________________PCP Address and Phone #: ________________________________IFSP Meeting Date: _____/_____/_____ (Date the IFSP team meets to begin development of the IFSP)45 days from referral is _____/_____/_____If the initial IFSP is over 45 days from referral indicate why: FORMCHECKBOX Child hospitalization FORMCHECKBOX Family requested delay FORMCHECKBOX Unable to contact/Family cancellation FORMCHECKBOX Provider issueIFSP Start Date: _____/_____/_____ (Date the family agrees to and signs the IFSP)6 Month Review Date _____/_____/_____RBI Completion Date: _____/_____/_____ If this is an Interim IFSP complete Cover Page, page 10,11 and 13.Child’s Name _____________________ DOB ____/____/____ Age ______ ID_______ Date ____/____/____Please describe the reason your child was referred to Early Intervention (EI):General Health (Consider Child’s growth/ development / medical history Pertinent family history or other important events Medications taken/reasons Established conditions Prematurity Pregnancy and birth summary (only if relevant to reason for referral) Has your child’s lead level been tested? FORMCHECKBOX Yes FORMCHECKBOX No Is there a concern for a high lead level? FORMCHECKBOX Yes FORMCHECKBOX No If Yes, Please explain. FORMTEXT ?????Tell us about your child’s nutrition and feeding (i.e. food preferences, diet, intake, swallowing, chewing): FORMTEXT ?????Sleep? (i.e. hours, patterns, routines): FORMTEXT ?????Child’s Name ____________________ DOB ____/____/____ Age ______ ID_______ Date ____/____/____Tell us about your general daily activities? (i.e. diapering, bathing, behavior, going out in the community): FORMTEXT ?????Does your child spend any time in a licensed early care and education setting? FORMCHECKBOX Yes FORMCHECKBOX NoCaregiver Location/Name: ___________________________________________________________Schedule________________________________________________________________________Hours/week _____________________________________________________________________Does your child spend any time in the care of another non-parental adult? FORMCHECKBOX Yes FORMCHECKBOX NoCaregiver Location/Name: ___________________________________________________________Schedule________________________________________________________________________Hours/week _____________________________________________________________________Please share any information that may be helpful in supporting your family’s culture such as important holidays, cultural traditions, church, food, customs: FORMTEXT ?????Child’s Name ______________________ DOB ____/____/____ Age ________ ID________ Date ____/____/____4667253643630Who lives with this child?00Who lives with this child?THIS PAGE SHOULD BE FILED SEPARATELY FROM THE IFSP AS IT MAY CONTAIN SENSITIVE INFORMATION. This will prevent it from being copied outside EI.Are there any other circumstances affecting your child and family that could impact your child’s development? (i.e. safety, homelessness, trauma, illness, loss, financial stress, depression, addiction)? FORMTEXT ????? FORMCHECKBOX Initial EcoMap developed. An ECOMAP is a picture of the supports that surround your family. This picture will help us to get to know you better. The space in the center represents who lives with your child. We will draw lines that connect your family to those around you. The thicker the line the more supportive the relationship. Broken lines or dashes represent relationships that cause you stress. Please consider extended family, friends, and places of worship, clubs, pediatricians or specialist or agencies like WIC. This information will help EI get a better picture of your family’s supports and resources and will help us support you in the development of individualized ideas and strategies. 514540572390Caregiver 2 (Caregiver’s Family)0Caregiver 2 (Caregiver’s Family)-3429054610Caregiver 1 (Caregiver’s Family)Caregiver 1 (Caregiver’s Family)-36195204470Caregiver 1 FriendsPeople at WorkCommunity SupportsCaregiver 1 FriendsPeople at WorkCommunity Supports5678805204470Caregiver 2 Friends People at WorkCommunity SupportsCaregiver 2 Friends People at WorkCommunity Supports2214245765175Community Supports and ServicesCommunity Supports and ServicesChild’s Name _____________________ DOB ____/____/____ Age ______ ID_______ Date ____/____/____YesNo1 FORMCHECKBOX FORMCHECKBOX Does the parent have concerns about how the child hears?2 FORMCHECKBOX FORMCHECKBOX Have you noticed that the child does NOT startle in response to loud sounds? (< 6 months) FORMCHECKBOX FORMCHECKBOX Have you noticed that the child does NOT turn in response to sounds? (> 6 months) FORMCHECKBOX FORMCHECKBOX Have you noticed that the child does NOT follow simple spoken directions? (> 12 months)3A FORMCHECKBOX FORMCHECKBOX Has the child failed a hearing screen? (newborn or other)4 FORMCHECKBOX FORMCHECKBOX Is there anyone in the family who has hearing loss from childhood? (including extended family)5 FORMCHECKBOX FORMCHECKBOX Is anyone concerned about your childs language development? Approximately how many words does he/she use consistently? ______________________________________________________6 FORMCHECKBOX FORMCHECKBOX Was the child’s birth weight less than 3 pounds and 5 ounces?7B FORMCHECKBOX FORMCHECKBOX Does the child have a syndrome associated with hearing loss?8 FORMCHECKBOX FORMCHECKBOX Has the child had meningitis?9 FORMCHECKBOX FORMCHECKBOX Has the child had middle ear infections or fluid in the ears for more than 3 months?10 FORMCHECKBOX FORMCHECKBOX Does the child have a craniofacial anomaly, such as cleft lip/palate, skin tags near the ear, an ear pit (small hole), or other atypical ear formation?11C FORMCHECKBOX FORMCHECKBOX Did the child receive mechanical ventilation for more than 5 days?12D FORMCHECKBOX FORMCHECKBOX Did the child have a congenital infection?13 FORMCHECKBOX FORMCHECKBOX Did the child have jaundice (hyperbilirubinemia) to the point of needing a blood transfusion?14E FORMCHECKBOX FORMCHECKBOX Did the child receive ECMO?15 FORMCHECKBOX FORMCHECKBOX Did the child remain in the NICU for 5 or more days?If any of the answers above are “yes”, it is recommended that you schedule a comprehensive hearing test for your child by a licensed pediatric audiologist. Testing will ensure your child is hearing all the sounds we would expect. A copy of this hearing screening should be given to the audiologist. FORMCHECKBOX Family has received RI Early Intervention Guide to Your Child’s Hearing A). Has the child failed a hearing screen? If the child was born in RI, results can be obtained with a signed release form from the RI Hearing Assessment Program, phone 401-277-3700, fax 401-276-7813. If the child was born out of state and the parent is unaware if their child was tested or what the results were, you can consult to obtain contact information for that state. B). Does the child have a syndrome associated with hearing loss? There are over 300 syndromes associated with hearing loss. This is a list those that are more common:AchondroplasiaFetal Alcohol SyndromeTrisomy 13 or 18AlporHunter SyndromeTrisomy 21 (Down Syndrome)ApertNeurofibromatosisTurnerCharcot-marie-ToothOculo-Auriculo-Vertebral DysplasiaUsherCHARGE SyndromePendredWaardenburg SyndromeCrouzen or Cornelia de LangeTreacher CollinsC). Did the child have mechanical ventilation for more than 5 days? Mechanical ventilation is defined as ventilation with intubation. Nasal cannula and CPAP are not considered mechanical ventilation.D). Did the child have a congenital infection? Such as CMV (cytomegalovirus), herpes, toxoplasmosis, rubella, syphilis.E). Did the child receive ECMO? ECMO (extracorporeal membrane oxygenation) is a device that takes over the work of the lungs and sometimes the heart. It works by pumping the blood through an artificial lung, similar to a heart-lung bypass machine used in surgery. In this area, infants usually must be transferred to Massachusetts General Hospital to receive this type of care.1631954628515If any of the answers above are “yes”, it is recommended that you schedule a comprehensive vision assessment for your child with a pediatric aphthalmologist. A copy of this vision screening should be given to the ophthalmologist. 0If any of the answers above are “yes”, it is recommended that you schedule a comprehensive vision assessment for your child with a pediatric aphthalmologist. A copy of this vision screening should be given to the ophthalmologist. Child’s Name _____________________ DOB ____/____/____ Age ______ ID_______ Date ____/____/____YesNoQuestions1 FORMCHECKBOX FORMCHECKBOX Is there a family history of serious childhood eye disease?*2 FORMCHECKBOX FORMCHECKBOX Do your child's eyes appear to cross, turn in or wander?3 FORMCHECKBOX FORMCHECKBOX Does your child squint in normal lighting?4 FORMCHECKBOX FORMCHECKBOX Does your child turn his/her head to an abnormal position when looking at things?5 FORMCHECKBOX FORMCHECKBOX Have you noticed back and forth movements of your child’s eyes? (nystagmus)6 FORMCHECKBOX FORMCHECKBOX Does your child repeatedly poke at his/her eyes or repeatedly rock his/her head back and forth?7 FORMCHECKBOX FORMCHECKBOX Have your child's eyes been injured?8 FORMCHECKBOX FORMCHECKBOX Was your child born prematurely or on oxygen while in the hospital?**9 FORMCHECKBOX FORMCHECKBOX Does your child have any health condition that might affect vision? (refer to list below)***10 FORMCHECKBOX FORMCHECKBOX Do you have concerns or have you noticed anything unusual about your child’s vision? (If yes, please specify)11 FORMCHECKBOX FORMCHECKBOX Are you or anyone else concerned that your child is not looking at faces, objects or activities happening around them?* 1. A positive family history for childhood diseases, such as, childhood cataracts, strabismus, amblyopia (lazy eye), glaucoma, retinal problems, retinoblastoma, or nystagmus increases the likelihood that the child may have similar problems.** 8. Children who were premature are at a greater risk for developing amblyopia, high myopia (nearsightedness), and strabismus.*** 9. Conditions that require vision screening in infants and children include but are not limited to: Down SyndromeAlbinismMarfan SyndromeCerebral PalsyCHARGE SyndromeGalectesemiaSpina BifidaOsteogenesis ImperfectaHomocystinuriaTuberous SclerosisTrisomy 13Trisomy 18Child’s Name _____________________ DOB ____/____/____ Age ______ ID_______ Date ____/____/____Where was the evaluation conducted? ____________________________________________________________________Was the child’s behavior and participation typical? surprising? Please explain. FORMTEXT ?????Evaluation Team: ___________________________ ___________________________ ____________________________(Including Family) Name/Role: Name/Role: Name/Role: ___________________________ ___________________________ ____________________________ Name/Role: Name/Role: Name/Role: Methods / Procedures Used For Evaluation/Assessment: Check all that apply: FORMCHECKBOX Standardized tool _______________ FORMCHECKBOX Checklist FORMCHECKBOX Review of medical record FORMCHECKBOX Interview FORMCHECKBOX Observation. Please list other methods and procedures on the lines below:_________________________________ _________________________________ __________________________________ FORMCHECKBOX Eligible: This child meets the eligibility criteria for early intervention services. Check #1 OR #2 1. FORMCHECKBOX Single Established Condition (Specify) Primary Diagnosis: ___________________________________________ ICD-10 Code: _________________Secondary Diagnosis: _________________________________________ ICD-10 Code: __________________2. FORMCHECKBOX Significant Developmental Delay (Select Eligibility Category a, b, or c )Primary Diagnosis: ____________________________________________ ICD-10 Code: _________________a) A delay of 2 standard deviations in at least one of the following area(s) FORMCHECKBOX Cognitive FORMCHECKBOX Gross Motor FORMCHECKBOX Fine Motor Skills FORMCHECKBOX Expressive Communication FORMCHECKBOX Receptive Communication FORMCHECKBOX Social Emotional FORMCHECKBOX Adaptive Skillsb) A delay of 1.5 standard deviations in at least two of the following area(s) FORMCHECKBOX Cognitive FORMCHECKBOX Gross Motor FORMCHECKBOX Fine Motor Skills FORMCHECKBOX Expressive Communication FORMCHECKBOX Receptive Communication FORMCHECKBOX Social Emotional FORMCHECKBOX Adaptive Skillsc) There is a significant impact on child/family functioning in the following area(s) FORMCHECKBOX Cognitive FORMCHECKBOX Gross Motor FORMCHECKBOX Fine Motor Skills FORMCHECKBOX Expressive Communication FORMCHECKBOX Receptive Communication FORMCHECKBOX Social Emotional FORMCHECKBOX Adaptive Skills FORMCHECKBOX Vision FORMCHECKBOX Hearing FORMCHECKBOX Health FORMCHECKBOX Family Circumstance FORMCHECKBOX Not Eligible: This child does not meet the eligibility criteria for EI services (Summarize on Form B). Reminder: Provide procedural safeguards and document on Services Rendered Form. FORMCHECKBOX Family declined Early Intervention servicesScores: Indicate Standard Score (SS) (This is the same as Composite Score) Results: Indicate if 2 SD or 1.5 SD, WNL (Within Normal Limits) or SIF (Significant Impact on Functioning). If result is less than 1.5 SD, indicate <1.5 SD. Significant Impact on Functioning must be described in Child Outcomes Summary Section B. For Hearing and Vision use WNL or FER (Further Evaluation Recommended). Please note: 2 SD below mean = (SS=70 or below), 1.5 SD below mean = (SS=71-77) and in general, Standard Scores (SS) between 85 and 115 are considered to be within normal limits.Developmental Area ReviewedScoreResultsDevelopmental Area ReviewedScoreResultsDevelopmental Area ReviewedScoreResultsCognitive FORMTEXT ????? FORMTEXT ?????Gross Motor Skills FORMTEXT ????? FORMTEXT ?????VisionN/A FORMTEXT ?????Expressive Communication FORMTEXT ????? FORMTEXT ?????Social Emotional FORMTEXT ????? FORMTEXT ?????HearingN/A FORMTEXT ?????Receptive Communication FORMTEXT ????? FORMTEXT ?????Adaptive Skills FORMTEXT ????? FORMTEXT ?????Family CircumstanceN/A FORMTEXT ?????Fine Motor Skills FORMTEXT ????? FORMTEXT ?????HealthN/A FORMTEXT ?????Response to Referral Source: If this is the initial evaluation, did you send a response to the referral source? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A Child’s Name _____________________ DOB ____/____/____ Age ______ ID_______ Date ____/____/____Child Outcome Summary (COS) Section B: Use multiple sources of information, including COS Section A, to describe this child’s functioning in each outcomes area. Identify how these skills compare to same age peers using language such as age expected, skill like that of a younger child and/or a much younger child. Information provided by: FORMCHECKBOX Parent/Guardian FORMCHECKBOX Caregiver FORMCHECKBOX EC Teacher FORMCHECKBOX EI/ECSE Educator FORMCHECKBOX EI/ECSE Therapist FORMCHECKBOX Other____________________Outcome 1: Positive Social Emotional Skills (Including Social Relationships):Involves how the child relates to adults and other children, and for older children, how the child follows rules related to interacting with others. The outcome is measured based on how the child forms secure relationships with adults and children, expresses feelings, learns rules and expectations, and interacts socially.Skills expected of a child this age (age expected)Skills like that of a younger child; lead to age-expected (immediate foundational)Skills of a much younger child; earlier skills (foundational)Check one: FORMCHECKBOX Entry FORMCHECKBOX ExitYour child's assessment summary is organized around?the three?national Early Intervention outcomes. As we know, children’s functional abilities overlap the domains of development, therefore we organize what we know about your child into the three outcome areas. This summary will?summarize your child’s development, strengths, needs and how your child’s development compares to his/her same age peers.Child’s Name _____________________ DOB ____/____/____ Age ______ ID_______ Date ____/____/____Outcome 2: Acquiring and Using Knowledge and Skills: Involves thinking and reasoning, remembering, problem solving, using symbols and language, and understanding the physical and social world. The outcome is measured based on a child’s exploration and imitation, as well as his or her understanding of object permanence, symbolic representation, numbers, classification, spatial relationships, expressive language and communication, and for older children, early literacy.Skills expected of a child this age (age expected)Skills like that of a younger child; lead to age-expected (immediate foundational)Skills of a much younger child; earlier skills (foundational)Check one: FORMCHECKBOX Entry FORMCHECKBOX ExitYour child's assessment summary is organized around?the three?national Early Intervention outcomes. As we know, children’s functional abilities overlap the domains of development, therefore we organize what we know about your child into the three outcome areas. This summary will?summarize your child’s development, strengths, needs and how your child’s development compares to his/her same age peers.Child’s Name _____________________ DOB ____/____/____ Age ______ ID_______ Date ____/____/____Outcome 3: Taking Action to Meet Needs: Involves communicating/taking care of basic needs such as showing hunger, getting from place to place, using tools like a fork, toothbrush or crayon, and for older children, contributing to their own health and safety. The outcome is measured based on a child’s ability to integrate motor skills to complete tasks, self-help skills (e.g., dressing, feeding, grooming, toileting, and household tasks), and “act on the world to get what one needs.”Skills expected of a child this age (age expected)Skills like that of a younger child; lead to age-expected (immediate foundational)Skills of a much younger child; earlier skills (foundational)Check one: FORMCHECKBOX Entry FORMCHECKBOX ExitYour child's assessment summary is organized around?the three?national Early Intervention outcomes. As we know, children’s functional abilities overlap the domains of development, therefore we organize what we know about your child into the three outcome areas. This summary will?summarize your child’s development, strengths, needs and how your child’s development compares to his/her same age peers.Child’s Name _____________________ DOB ____/____/____ Age ______ ID_______ Date ____/____/____Child Outcomes Summary (COS) Section CHow would you summarize this child’s development in each outcome area? Review and select a statement for each outcome and record in the box below. ?Relative to same age peers, this child has all the skills we would expect for a child his/her age. (7) ?Relative to same age peers, this child has the skills we would expect for a child his/her age, however there are concerns that he/she may be on the border of not keeping up with same age peers. (6)?Relative to same age peers, this child shows many age expected skills, but also shows some functioning that might be described like that of a slightly younger child. (5)?Relative to same age peers, this child shows occasional use of some age expected skills, but more of his/her skills are not yet age expected. (4)?Relative to same age peers, this child is not yet using skills expected of his/her age but does use many important and immediate foundational skills upon which to build. (3)?Relative to same age peers, this child is showing some emerging or immediate foundational skills upon which to build. (2)?Relative to same age peers, this child’s functioning might be described as that of a much younger child. He/she shows some early skills but not yet any immediate foundational or age expected skills. (1)OutcomeNumerical Rating (Chose one for each Outcome)Exit Only:Has this child made progress in this outcome?(Choose one for each Outcome)1Positive Social Emotional Skills (Including Social Relationships)_____ FORMCHECKBOX YES FORMCHECKBOX NO2Acquiring and Using Knowledge and Skills_____ FORMCHECKBOX YES FORMCHECKBOX NO3Taking Action to Meet Needs_____ FORMCHECKBOX YES FORMCHECKBOX NONo exit rating due to: FORMCHECKBOX Child enrolled less than 6 months FORMCHECKBOX Lack of information due to loss of contact with child/familyChild’s Name _____________________________________ DOB _____/_____/_____ ID# _________ Outcomes are like goals…they reflect the changes families would like to see happen for themselves and their children. They are based on your concerns and priorities and are related to the development of your child. We will make them measurable so we can track progress.# FORMTEXT ?????a.) What we want to see happen for our child/family as a result of early intervention supports and services? FORMTEXT ?????Date Written ____/____/____Date Reviewed____/____/____ FORMCHECKBOX Periodic /6 Mo. FORMCHECKBOX Annual IFSP Other ____/____/___Parent Initials _______Additional Review:Date Reviewed____/____/____Parent Initials _______b.) How will we know your child/family has made progress? FORMTEXT ?????c.) Progress Review: Outcome is: FORMCHECKBOX Continued FORMCHECKBOX Achieved FORMCHECKBOX Modified/New Outcome Written # FORMTEXT ?????a.) What we want to see happen for our child/family as a result of early intervention supports and services? FORMTEXT ?????Date Written ____/____/____ Date Reviewed____/____/____ FORMCHECKBOX Periodic /6 Mo. FORMCHECKBOX Annual IFSP Other ___/____/___Parent Initials _______Additional Review:Date Reviewed____/____/____Parent Initials _________b.) How will we know your child/family has made progress? FORMTEXT ?????c.) Progress Review: Outcome is: FORMCHECKBOX Continued FORMCHECKBOX Achieved FORMCHECKBOX Modified/New Outcome Written Child’s Name ____________________________________ DOB _____/_____/_____ ID# _________Check and date applicable area FORMCHECKBOX Interim: ___/___/___ FORMCHECKBOX Initial: ___/___/___ FORMCHECKBOX Annual: ___/___/___ FORMCHECKBOX Update:__/__/__Services and supports are determined after IFSP outcomes are developed.EI ServiceProvider (Name)LocationMethod I/G* Natural Setting Yes / NoFrequency(# of times per wk/mo)Intensity(length of session)Date of InitiationDuration (months)StatusA AddE End FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ??? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????* If NO, complete page 12 “Plan for Providing Services in the Natural Environment”Services: ? Assistive technology? Audiology? Family Training/Counseling ? Nursing services ? Nutrition? Occupational therapy? Physical therapy? Psychology? Social work ? Speech/language therapy? Vision Location Codes:H (Home) C (Community) EIGC (EI Group in the Community)CB (Center Based) N/A (Not Applicable) Method:I (Individual) G (Group)Service Coordination is provided to coordinate services on the IFSP and could consist of home visits, telephone calls, and conversations with other providers. Early Intervention is able to provide interpretation, translation, and transportation services for families as needed to access EI programs and services.Services that are in place or are needed: (services such as medical, recreational, religious or social, while not covered by Early Intervention, contribute to this plan) Program/AgencyContactStatus FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Complete this Section for Updates and Annual IFSP Review OnlyParental Consent: I understand and agree to the changes in the IFSP services listed above. I also understand that this is my prior written notice to starting the services listed above. Parent/Guardian Signature:__________________________________________________________________ Date______/_______/______ Child’s Name ____________________________________ DOB _____/_____/_____ ID# _________ Service/Location: FORMTEXT ?????Explain why the child’s outcome(s) could not be achieved if service were provided in the child’s natural environment? (What are the barriers? How does the team know?) FORMTEXT ?????How will the family participate in achieving this outcome? (How will the family be coached to practice these strategies and skills in everyday routines and activities?) FORMTEXT ?????What is needed to address this outcome within the child’s typical daily routines and family activities? (Who is responsible? What is the timetable? What is needed? How will the family be supported?) FORMTEXT ?????Review Date: _____/_____/_____ FORMCHECKBOX Continue FORMCHECKBOX Change FORMCHECKBOX Achieved Please summarize child’s progress and changes that would be helpful: FORMTEXT ?????Review Date: _____/_____/_____ FORMCHECKBOX Continue FORMCHECKBOX Change FORMCHECKBOX Achieved Please summarize child’s progress and changes that would be helpful: FORMTEXT ?????Child’s Name ________________________________ DOB _____/_____/_____ ID# _________+Acknowledgement of the IFSP FORMCHECKBOX I give my consent to implement this Individualized Family Service Plan for my child and family as written. FORMCHECKBOX I give my consent to implement this Individualized Family Service Plan for my child and family with the following changes: ______________________________________________________________________________________________________________________________________________ FORMCHECKBOX I understand that early intervention services will be paid by private health insurance, Medicaid or state funds. FORMCHECKBOX I understand that this is my prior written notice to begin the services listed on the IFSP. FORMCHECKBOX I have received a copy of my procedural safeguards. These rights have been explained to me and I understand them.Parent/Guardian Signature: ________________________________ Date: ____/____/____ -120650361950 ~For Interim IFSPs Only~I understand that this is an Interim IFSP and that it is a temporary plan developed for children who are eligible for Early Intervention and are in need of immediate services. I also understand that a full IFSP still needs to be completed. Parent’s initials: ___________ Date: ____/____/_____00 ~For Interim IFSPs Only~I understand that this is an Interim IFSP and that it is a temporary plan developed for children who are eligible for Early Intervention and are in need of immediate services. I also understand that a full IFSP still needs to be completed. Parent’s initials: ___________ Date: ____/____/_____Other Team Member:____________________________________ Date: ____/____/____ ................
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