EITP | Early Intervention Training Program



Child’s Name: FORMTEXT ?????EI #: FORMTEXT ?????Date: FORMTEXT ?????SECTION 1: FAMILY CONSIDERATIONS- (Optional)1.How would you describe your child? FORMTEXT ?????The following would be helpful in the weeks or months ahead: FORMCHECKBOX Meeting other families whose child has similar needs FORMCHECKBOX Finding or working with doctors or other specialists FORMCHECKBOX Coordinating your child's medical care FORMCHECKBOX Finding out more about the services your family is receiving or could be receiving FORMCHECKBOX Finding new places to go in my community FORMCHECKBOX Planning for the future FORMCHECKBOX Transportation FORMCHECKBOX Child Care FORMCHECKBOX Finding someone to help out in my home (respite) FORMCHECKBOX Housing. clothing, jobs, food, telephone FORMCHECKBOX Safety FORMCHECKBOX Finding a support group FORMCHECKBOX Support/information for brothers, sisters, friends, relatives and/or others FORMCHECKBOX Information about my child's needs FORMCHECKBOX Help with insurance, SSI, Medicaid, Kid Care and/or DSCC FORMCHECKBOX Recreation - fun things to do as a family FORMCHECKBOX Other: FORMTEXT ?????2.What are some great things about your family? FORMTEXT ?????3. What are some things you find challenging or difficult? FORMTEXT ?????4. Is there anything else you think would be helpful for others to know about your child or your family? FORMTEXT ?????Describe a typical day for your child and/or family: Morning: FORMTEXT ?????Lunchtime: FORMTEXT ?????I'm concerned about and/or interested in my child's: FORMCHECKBOX Moving, crawling and/or walking FORMCHECKBOX Communicating FORMCHECKBOX Learning FORMCHECKBOX Feeding, nutrition FORMCHECKBOX Having fun with other kids FORMCHECKBOX Challenging behaviors or emotions FORMCHECKBOX Sleep patterns FORMCHECKBOX Equipment or supplies FORMCHECKBOX Health or dental care FORMCHECKBOX Pain or discomfort FORMCHECKBOX Vision or hearing FORMCHECKBOX Other: FORMTEXT ?????Afternoon: FORMTEXT ?????Dinnertime: FORMTEXT ?????Evening: FORMTEXT ?????Bedtime: FORMTEXT ?????I understand that provision of this information on this page is voluntary and if I provide this information, it will be shared with the service plan team members and others indicated in this plan. FORMCHECKBOX I agree to provide this information FORMCHECKBOX I do not agree to provide this informationSignature: Date: (R11/2016) Child’s Name: FORMTEXT ?????EI #: FORMTEXT ?????Date: FORMTEXT ?????SECTION 3: FUNCTIONAL OUTCOME #: FORMTEXT ??(May be used as an Annual goal statement for Part B Preschool Services.)Develop one outcome per page. Assign outcome # to identify each page individually. Each outcome may have several services, strategies and/or activities designed to facilitate the achievement of the outcome.*** Family Priorities (Concerns) FORMTEXT ????? What do we want for FORMTEXT ????? and our family? (What does the family want and why?)How will we achieve this outcome? (List strategies and/or activities designed to facilitate the achievement of this outcome and/or steps to be taken to link us to services and/or secure funding for services if not required to be provided by the Part C Early Intervention System)What Early Interventionand/or otherservices and supports wouldhelp us with this?Fund SourceUpon review, how are we doing? Has our outcome been achieved? Should our outcome, strategies, activitiesand/or services change? If so, how? Written parentalconsent required to change any services. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????FOR EARLY INTERVENTION PARTICIPANTS ONLY: The primary setting for young children is within the context of the family, their home, their community, lifestyle and daily activities, routines and obligations. To the extent appropriate, services must be provided in the types of settings in which young children without and their families would participate. Are all Part C EI services needed to achieve this outcome being provided in natural environments? FORMCHECKBOX Yes FORMCHECKBOX NoIf no, justify the extent to which any services will not be provided in natural environments: FORMTEXT ?????Note regarding Fund Source: All Part C Early Intervention Services must be pre-authorized. For all other services identified as needed but not required to be provided by the Part C Early Intervention System, indicate the fund Source (i.e. Medicaid, DSCC, private insurance) which is either responsible for payment or from which payment is being sought.(R11/2016) Child’s Name: FORMTEXT ?????EI #: FORMTEXT ?????Date: FORMTEXT ?????SECTION 7. IMPLEMENTATION AND DISTRIBUTION AUTHORIZATIONRequired to implement servicesThe purpose of the required "Implementation and Distribution Authorization" signature page is: 1) to certify that the family consents to the Early Intervention (EI) services outlined in the IFSP implementation and 2) to indicate who may view or receive copies of the IFSP and who the family consents may exchange verbal/ written information about the eligible child.FOR EARLY INTERVENTION (EI) PARTICIPANTS ONLYThe contents of the IFSP have been fully explained to me and if I agree to the services, I understand they must be provided. I understand that I may refuse any or all of the services offered by the Part C EI Program but that if I do, my child may not receive those services through the Part C EI Program. I also understand that I may request dispute resolution regarding the services offered and receive the undisputed services while the dispute is being resolved, or if I already have an IFSP, continue to receive the services currently being provided, while the dispute is being resolved. I understand and agree that individual EI provider changes may occur during the course of services, which do not require additional written consent on this page if the service type, frequency, duration, and location are maintained.I understand a new signed Child and Family Connections Consent for Release of Information will be required for any EI Providers not listed below by name/discipline, prior to services beginning and in order to receive a copy of the IFSP.In order to implement delivery of EI services, I understand that this IFSP will be distributed to EI providers and their agencies if applicable, listed below. I consent to the verbal and written exchange of information between members of my child’s IFSP Team.I understand that this IFSP must be reviewed every six (6) months or more often if necessary. Finally, I understand that the Illinois Department of Human Services, as lead agency for the Part C EI Program, may refuse reimbursement for services not required to be funded by the Part C EI Program and is payor of last resort for all services required to be funded by the Part C EI Program. I hereby waive further notice regarding the EI services agreed to. FORMCHECKBOX I hereby consent to all EI services herein. FORMCHECKBOX I hereby consent to all EI services herein, except: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX I hereby refuse all EI services offered herein.I consent to the following individuals/agencies to receive a copy of this IFSP and any revisions made to it.NameRoleAddressPhone # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Parent/Caregiver Signature: Date: Other Signature: Relationship: Date:(R07/2019)Child’s Name: FORMTEXT ?????EI #: FORMTEXT ?????Date: FORMTEXT ?????Date: FORMTEXT ?????SECTION 8. MEETING PARTICIPANT/CONTRIBUTOR LISTDate: FORMTEXT ?????Date: FORMTEXT ?????Initial Service Plan MeetingService Plan Review Meeting FORMCHECKBOX 6 Month FORMCHECKBOX Annual FORMCHECKBOX OtherName Role .Participated/ContributedName Role .Participated/Contributed 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 ?Service Plan Review Meeting FORMCHECKBOX 6 Month FORMCHECKBOX Annual FORMCHECKBOX OtherService Plan Review Meeting FORMCHECKBOX 6 Month FORMCHECKBOX Annual FORMCHECKBOX OtherName Role .Participated/ContributedName Role .Participated/Contributed 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 ?(R11/2016) ................
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