Care Coordinator: - Hawaii



INDIVIDUALIZED

FAMILY SUPPORT PLAN

|CHILD’S NAME: | |

|CARE COORDINATOR: | |

|PROGRAM: | |

|Select Type of IFSP |Date: |Date Meeting Held |If Annual IFSP, date of Initial IFSP: |If annual, enter date of|

|Please check one: Initial IFSP Annual IFSP | | | |Initial IFSP |

| |6-month IFSP Review |Date: |Date Meeting Held |Other IFSP Review Date(s): |List all dates of IFSP Review(s) between Initial and the next |

| | | | | |Annual IFSP, excluding the 6-month Review. |

INFORMATION ABOUT OUR CHILD AND FAMILY

|Purpose: This section provides an opportunity for the family members to think about and share their hopes, dreams, and concerns for their child and realize that they have strengths and resources that can be used to address |

|their concerns and priorities. |

|The information in this section will be primarily guided by the family and should be addressed during the course of service delivery. This section is not designed to be a question and answer format, but to be done in more |

|of a “talk story” fashion. If family feels comfortable, offer choice of having them fill out this section. Check with the family about the content and wording of information before writing it down. It is important to use |

|the family’s words as much as possible. Families can choose what information they want written on the IFSP. NOTE: It is not optional for the care coordinator to have a discussion regarding concerns, priorities and |

|resources. However, it is important that families know they can choose not to include information in any section (if so, check the appropriate box). |

A. OUR CHILD’S STRENGTHS/QUALITIES:

|This area should contain a summary of the child’s strengths and qualities as identified by the family. List whatever information the family agrees to have written down using their own words as much as |

|possible. The following types of questions may be used to encourage the family to talk about their child. What are your child’s likes and dislikes? How would you describe your child’s personality? What |

|does your child enjoy doing? What is your child good at doing? Try to be specific, by encouraging the family to explain or give examples of what they mean. Additional strengths/qualities noted by other |

|members of the IFSP team may be written down if the family agrees. |

B. OUR FAMILY’S STRENGTHS AND RESOURCES: (Family declined to complete this section YES )

|This area should contain a summary of the family’s strengths, qualities, and resources as they relate to their child’s development. It may include the people, skills, capacities, relationships, and concrete |

|assets (e.g., insurance) that the family has, or has access to, which support and sustain the family. List whatever information the family chooses to share and agrees to have written down, using their own |

|words as much as possible. Additional strengths that have been noted by the IFSP team in the course of getting to know the family may also be included if the family agrees. |

| |

|The following types of questions may be used to encourage the family to share about their strengths and resources. Describe your family (e.g., single parent, married, supportive spouse). Who would you list |

|as part of your family? If something happens to a family member, who would you call for help/support? What kinds of things do you do together as a family? How often? Describe a typical day for your |

|family. What kinds of cultural values and traditions have been helpful to you and your family)? |

| |

|NOTE: Try to get specific information, but be sensitive to what family is comfortable sharing. |

C. CONCERNS FOR OUR CHILD AND FAMILY: (Family declined to complete this section YES )

|This area should contain a summary of circumstances related directly or indirectly to the child’s development, which worry, distress, or create difficulties for the family. List concerns the family has |

|identified and agreed to include in this section. Also, explore with the family the concerns brought up by the pediatrician, specialists, or other team members regarding their child’s development. Explore |

|possible behavioral and/or emotional concerns (e.g. temper tantrums, etc.). What could their child benefit from to enhance his/her development? Any major stressors? (e.g. financial, difficult work |

|schedule, or any family members ill that family provides care for, no child care, divorce). If team members are concerned about something, but the family feels strongly that they are not important issues |

|at the present time, the family’s wishes need to be respected. Discussion should be noted here or on the IFSP Meeting Notes Page. Example: “Family not concerned about child’s speech development at this |

|time.” Use the family’s words and avoid professional jargon. |

D. PRIORITIES FOR OUR CHILD AND FAMILY: (Family declined to complete this section YES )

|This area should contain a summary or list of the family’s priorities for their child and family as they relate to their child’s development. Family priorities are goals or accomplishments that are important|

|to the family. What would the family like to see for their child in the future? What are the family’s hopes and dreams for their child? The family can rank their concerns in order of importance. It is not|

|necessary to address all the concerns that have been identified in Section C. Asking the family which of the items on the list are the most important right now (e.g. ”Which should we start with?”) sometimes|

|helps the family rank them. Remember that you will be referring back to this section when developing the outcomes to ensure that all their priorities are addressed. All priority areas identified must be |

|addressed in outcomes unless otherwise specified by the family. |

| |

|REMINDER: If the family’s priorities are different from the service provider’s, it is important to remember that under Part C, the family’s priorities take precedence. Perhaps at a later date the issues that|

|are important to the service provider will also become important to the family. |

E. CHILD’S PRESENT LEVELS OF DEVELOPMENT

Purpose: This section serves as a summary of information that has been gathered regarding the child’s present abilities, strengths, and needs. The information must be based on current (within 3 months) evaluation/assessment results, observations, parent, medical, and other reports. This section must also include statements of the child’s present levels of development. This section must be completely up-dated at Initial IFSP, 6-month Review IFSP, and Annual IFSP.

|Area |Date |Information From (Source) |Present Levels of Development |

| |Insert date of when |List sources where present |Include short narrative of skills, emerging skills and age expected skills not observed. May also add specific|

| |evaluation/ |levels of development were |source with narrative (i.e., Per Pediatrician…; Per Mom…). If the test could not be completed, make a notation|

| |assessment/screening was |obtained. |that the domain(s) was not administered and include any observations about the child’s developmental skills. |

| |completed and/or | | |

| |information gathered. | |NOTE: Do not remove sub-headings (“description of skills,” “Emerging skills,” “Age expected skills not |

| | | |observed.” |

|Health | |To be based on |Provide information that describes any medical conditions or other health issues (e.g. “asthma episodes”) that |

| | |professionally acceptable |may impact the service provision. If there are no health issues to report, simply note fact (e.g., “Child has |

| | |objective criteria (i.e., |been healthy during the past six months and all immunizations are up to date”). May include other significant |

| | |evaluation tool – Battelle |medical information such as Apgar scores, weight/height, immunization, and prenatal/postnatal history (e.g., |

| | |Developmental Inventory-2; |gestational diabetes, emergency cesarean, etc). |

| | |Pediatrician report; Parent| |

| | |Report; etc.). | |

|Vision | | |Note any vision screening or evaluation that has been completed and any recommendations for re-screening. |

| | | |Provide information on the child’s visual skills/abilities. |

|Hearing | | |Note any hearing screening(s) or evaluation that has been completed and any recommendations for re-screening. |

| | | |Newborn Hearing screening may be obtained from Newborn Hearing Screening Program. Include history of ear |

| | | |infections, ear tubes, hearing loss, etc. Provide information on the child’s hearing skills/abilities. |

|Adaptive | | |Describe skills related to daily living such as how the child takes care of self (e.g. eating, dressing, |

|(Self-Care/Personal Responsibility) | | |toileting), demonstrates independence, helps with simple household chores, etc. |

|Social Emotional/Personal-Social | | |Describe how the child shows feelings, relates to other people, and develops self-concept. For example how an |

|(Adult Interaction, Peer Interaction, | | |infant/child interacts with children and adults, plays with others, and show his/her independence. |

|Self-Concept and Social Role) | | | |

|Communication | | |Describe how the child expresses and understands ideas. Include what the child is saying/expressing and |

|(Receptive Language/Expressive Language) | | |understanding, and how the child communicates (gesturing, signing, using pictures, pointing, etc.). |

|Motor | | |Describe the child’s gross motor skills such as head control, sitting, crawling, walking, climbing, etc. |

|(Gross Motor-Body Movements/Fine | | |Include large muscle involvement and body tone (rigid or “floppy”). For fine motor skills, describe the |

|Motor-Hand Skills/Perceptual Motor-Eye | | |child’s use of arms, hand, and fingers. Examples may include small muscle development, using one or both |

|Hand Coordination) | | |hands, picking up small objects, eye hand coordination, and manipulation of objects. For perceptual motor |

| | | |skills, include such items as placing objects into containers, stacking pre-writing skills, etc. |

|Cognitive | | |Describe the child’s ability to utilize vision/auditory information; attends and retrieves information; ability|

|(Attention and Memory/Reasoning and | | |to use critical thinking/problem solving. This may include how the child plays with toys, explores the |

|Academic Skills/Perception and Concepts) | | |environment, and sorting/matching objects. |

II. OUTCOMES (Use a separate page for each outcome.)

|Date: |Date Outcome Added | |

|Outcome #: |Number each |What do we want for our child/family?: Indicate, using the family’s words, the desired outcome for the child and/or family relating directly or indirectly (e.g. housing, financial,|

| |outcome |childcare assistance, other family concerns, etc.) to the child’s development. |

| |consecu-tively.| |

| |

|What is happening now with our child/family? |Indicate how the child is currently functioning in the particular outcome area or current family status. |

| |

OBJECTIVES: Steps to reach outcomes (each objective must be measurable, have a time frame, and include how progress will be evaluated)

STRATEGIES: Activities for working on the objective during our child and family’s daily activities/routines.

REVIEW: At IFSP review meeting, record any progress and changes toward reaching our child/family outcomes/objectives. Also, indicate if objectives have been MET, PROGRESSING, DISCONTINUED or MODIFIED.

|OBJECTIVE |Number the Objectives to coincide with the Outcome. If a new Objective is added at an IFSP Review Meeting, include the date in parenthesis next to the Objective Number. |

| | |

| |Through a collaborative discussion with the family and other team members, smaller, measurable steps (objectives) are developed and indicated here. Each objective must be 1) measurable, 2) have a|

| |time frame, and 3) have a statement on how progress will be obtained/reported. Indicate the approximate time frame for reaching each objective. An exact date is not necessary. Time frames can |

| |be reported in the number of months or an expected date. Time frames should reflect an appropriate sequence of implementation for the objective. |

|STRATEGIES |Number the Strategies to coincide with the Objective. |

| | |

| |Indicate the ways in which the child can learn the skills needed to make progress towards meeting the outcome/objective. Strategies must be associated with the child and family’s daily routines. |

| |Also indicate who will be actively involved in the strategies, e.g. parents, peers, siblings, grandparents, childcare providers, other caregivers, and other professionals. If applicable, may |

| |refer to Strategy/Activity Sheet that has been individualized for the child and family. |

| | |

| |NOTE: The Strategy/Activity sheet does not need to be attached to the IFSP; however, must be kept in the child’s chart and must be distributed to the Care Coordinator, Family, and all other |

| |providers implementing the IFSP. |

|REVIEW |This area should indicate the progress towards reaching the child/family outcomes. Record and date any progress and changes at the time of the IFSP Review; also determine if the objectives have |

| |been MET, PROGRESSING, MODIFIED, or DISCONTINUED. |

| | |

| |MET: is when objective is achieved. If child exceeds the objective, you may elaborate. |

| |PROGRESSING: is when objective is only partially met or skill is emerging. Record any progress and changes toward reaching the outcome/objective. |

| |MODIFIED: is when an objective has been changed. |

| |DISCONTINUED: is when family and/or team decide that objective is no longer appropriate or a concern. |

| | |

| |NOTE: As part of the Annual IFSP meeting, the current IFSP objectives must be reviewed. The Review Status section must be completed with a date and parent initial. If the objective is not met |

| |and the team determines that it will be continued, transfer (re-write) the objective on the Annual IFSP. Renumber if needed. |

III. TRANSITION PLAN

Purpose: This section addresses steps taken upon the initiation of early intervention services to support the transition of the toddler, upon reaching the age of three or developmental milestones, to preschool Special Education Services (SPED) or to other community services as may be appropriate and based on family preferences.

NOTE: A transfer from one early intervention program to another early intervention program or from one placement to another (from foster family to biological family; from one early intervention program) could be developed as an outcome.

Transition Activities

• Activities A, B, C, D, and E are the required components of the IFSP Transition Plan. Section F only as needed. Middle column of Sections B. C, D, and E must include date of IFSP and a statement and statement in right column of Section A to be considered a “complete transition plan.” NOTE: Right hand column must have the IFSP date and a review statement for 6-Month Review and Annual IFSPs.

• Review all the components at every IFSP meeting and allow the family the opportunity to decide how and when they will participate in the transition planning process. Possible points of discussion are listed for each activity.

Strategies, Steps, & Decisions to support Transition Activities

• This section is used to document any decisions, steps and/or strategies that were discussed with the family to support each transition activity.

• Include who will be responsible for each step and any anticipated start dates and/or due dates for each step/strategy.

• Review, discuss and update this section of the Transition Plan at every IFSP meeting to add on any new steps, strategies, and/or decisions.

Review/Comments

• This section is used to review the strategies, steps and decisions.

• Discuss and update the progress and/or results of the steps and strategies at every IFSP meeting.

NOTE: Because the Transition Plan is an ongoing process over the span of time that the child and family is with EI, you may make a copy of the current IFSP Transition Plan page(s) and insert into the Annual IFSP and make revisions/updates accordingly.

|Outcome #: |To be used if team decides to make transition an outcome. Number accordingly if it is used as an outcome. If not used as an outcome then leave blank. |

| |

NOTE: Date all entries added to the IFSP

|Transition Activities |Strategies, Steps, & Decisions |Review / Comments |

|& Possible Points For Discussion |to Support Transition Activities |(in each block, enter date of the IFSP and |

| |(in each block, enter date of the IFSP and statement of plan related to |statement of review, including dates that the |

| |the transition activity and include any anticipated start dates and/or |activity occurred) |

| |due dates) | |

| | |NOTE: This column should be stated in “past” |

| |NOTE: This column should be stated in “future” tense – what will happen.|tense – what happened since the last IFSP. |

|A. Discussion regarding “transition” from Early Intervention: |This block remains blank because the discussion about when Part C |Upon entering the early intervention system, care |

|That Part C services will end at age three and/or when our child no longer meet Hawai‘i’s Part |services end will be completed at the initial IFSP meeting. |coordinators discuss with the family how children |

|C eligibility criteria. | |exit and what steps will take place to prepare for|

| | |the transition out of the early intervention |

| | |system. Inform the family that early intervention|

| | |services are provided until their child’s third |

| | |birthday and/or when their child has made progress|

| | |and no longer meets Hawai‘i’s Part C eligibility |

| | |criteria. Document the discussion here. |

|B. Discussion and training for our family regarding future services, placements, and other |After discussions with the family regarding the various options available|State what happened since the last IFSP regarding |

|matters: |to their child upon exiting the early intervention system, document any |future services, placements, and other matters. |

|Possible program options and services for our child when it is time to leave Early Intervention|steps, strategies, and/or decisions here. | |

|system, based on our child’s needs, our hopes and dreams for our child’s future and the | | |

|resources available. |If family does not want to explore this activity at this time, indicate | |

|Support our family needs to transition our child from one program to another (e.g. meet the |that it will be discussed at the next IFSP. | |

|teacher, visit classroom, training/consultation, etc.). | | |

|Follow up, if any, we would like from the EI program, within 3 months after the transition, |If the family would like support in the transition process and/or follow | |

|regarding our child’s status. |up after the transition, outline the steps in assisting/supporting the | |

| |family here. | |

|C. Discussion and procedures to help prepare our child for changes in service delivery: |If family would like support in this area, outline the steps in |State what happened since the last IFSP regarding |

|Support needed to help our child prepare for changes in services to support a smooth transition|assisting/supporting the child and family to help prepare their child for|procedures to help prepare the child for changes |

|from one program to another ( e.g. meet the teacher, visit classroom, training/consultation, |changes. |in service delivery. |

|etc.). | | |

|Skills our child may need to support a smooth transition into the next setting. |If family does not want to explore this activity at this time, indicate | |

| |that it will be discussed at the next IFSP. | |

|D. Transmission of information about our child to possible future service providers: |If families are interested in a specific program, discuss with family |State what happened since the last IFSP regarding |

|Written permission to share copies of Early Intervention generated information (reports, |about sharing information (evaluations/assessment/IFSP) with receiving |transmission of information about the child to |

|evaluations, IFSP, etc.) with the future service provider(s). |program to ensure continuity of services for their child. If family |possible future service providers. |

|Part C Transition Notice to the Department of Education (DOE), if applicable. Transition |agrees to share information, they must sign appropriate consent forms. | |

|Notice is due to DOE, 90-120 days prior to the child’s third birthday. | | |

| |If family does not want to explore this activity at this time, indicate | |

| |that it will be discussed at the next IFSP. | |

| | | |

| |For children who may be eligible for DOE Preschool Special | |

| |Education, complete the Part C Transition Notice to DOE. If the family | |

| |“opts out” of sending the Transition Notice, document the reason why | |

| |using the “Reasons List.” | |

|E. Part C Transition Conference for our family: |The care coordinator will schedule a Part C Transition Conference. The |State what happened since the last IFSP regarding |

|Schedule Part C Transition Conference meeting no later than 90 days and up to 9 months prior to|purpose of the Transition Conference is to give the family an opportunity|Part C Transition Conference. |

|transitioning from Early Intervention. |to explore all options available for their child (prior to making a | |

| |referral to any program). Document date of Transition Conference here. | |

| | | |

| |If family does not want to explore this activity at this time, indicate | |

| |that it will be discussed at the next IFSP. | |

| | | |

| |If family declines a Part C Transition Conference, document why, | |

| |including reason from the “Reasons List” and where the child will be | |

| |going upon exit of EI. (The family cannot decline a Part C Transition | |

| |Conference prior to 9 months of transitioning from Early Intervention). | |

| | | |

| |The care coordinator/family will invite representatives from the | |

| |program(s) of the family’s choice (such as DOE SPED preschool, community | |

| |preschools and other programs) to discuss the services the child may | |

| |receive. Use the Part C Transition Conference Meeting Notification to | |

| |identify and invite participants. | |

| | | |

| |Note: If the child may be eligible for DOE SPED preschool, care | |

| |coordinator/family must invite a representative from DOE to the Part C | |

| |Transition Conference. This is not in place of the Student Support Team | |

| |meeting (SST). | |

|F. Other Transition Planning Activities: |Only as needed. |State what happened since the last IFSP regarding |

| | |other transition activities. |

IV. SUMMARY OF EARLY INTERVENTION SERVICES:

Purpose: This section is a summary of early intervention services and supports necessary to meet the unique needs of the child and family to achieve the desired outcomes as previously written.

The decisions regarding what services and supports will be provided, including type, frequency, location, intensity, and duration, must occur only after the development of outcomes and strategies. Services that address the strategies are determined through discussion with the family and must be delivered as indicated in the IFSP. Family members and professionals are encouraged to talk about services and supports openly and to make joint decisions based upon the outcomes chosen by the parents or family members and the strategies developed by the team. The decision to provide a service or support may not be based solely upon factors such as: nature or severity of disability, age of child, availability of services, administrative convenience, family preference, and payment method or service provider preferences.

|Early Intervention Service Options |Method |Location |Funding Source |

|Assistive Technology |Occupational Therapy |Individual (I) |1. Home |DOH is the funding source for all Early |

|Audiological Services |Physical Therapy |Group (G) |2. Community Setting (e.g., Child care, Preschool,|Intervention Services unless parent |

|Care Coordination |Psychological Services |Consultation (C) |Shelter, etc.) |consents to bill Private Insurance. |

|Family Training/Counseling/Home Visiting |Sign Language & Cue Language |Primary Service Provider (P)* |3. Other (Non-natural environment – e.g., | |

|Health Services |Social Work Services | |Hospital, Office Setting, EIP, etc) | |

|Medical Diagnostic Services |Speech Language Pathology | | | |

|Nursing Services |Special Instruction | |NOTE: If “other,” include justification in | |

|Nutrition Services |Transportation | |Section V of IFSP. | |

| |Vision Services | | | |

|Date Service Added or Modified on IFSP |

|Early Intervention Service Option: Indicate here the type of “mandated “services or support that will be provided to the child and family. List all services and supports that the team has identified to meet the child and |

|family needs regardless of resource availability. Do not project services that might be delivered to avoid revising the IFSP. |

| |

|NOTE-1: List hearing services provided by the Hearing Specialist as “Special Instruction – Hearing Services.” |

| |

|NOTE-2: If interpretation services are needed on an on-going basis, make a note on the IFSP Meeting Notes page after discussing at the IFSP Meeting |

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|NOTE-3: One time evaluations should not be listed on the IFSP. |

| |

|NOTE-4: Document Transportation on the IFSP meeting notes page instead of the Services page. |

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|Related to Outcome #s: Indicate which outcome(s) is related to each mandated service listed for the child and family. |

| |

|Provider (Provider may change due to availability): For each mandated service received by the child and family, indicate the agency, program, or FFS provider who will be delivering the early intervention service or support. |

|Do not write the name of the person who will be delivering the service or support because a change of personnel would require a revision of the IFSP. |

| |

|Frequency/Intensity (How often, How long): For each service indicate the following: |

| |

|How often (frequency) the service will be delivered. Be specific. Use terms such as “one time a week” instead of “four times per month”. Do not use ranges or terms like “up to” or “as needed” since they do not help |

|families predict a schedule for delivery of services. |

|The length of time (intensity) the service will be delivered. Use terms such as “45 minutes.” |

|If the same service is provided in different locations at different frequencies, write as separate line items. |

|Document actual frequency and intensity of the face-to-face visit. |

| |

|NOTE: Write what the child needs, regardless if the resources are available or not. |

| |

|For example: If a child is to receive speech language pathology services weekly, frequency and intensity should be written as “ 1 time a week for 45 minutes.” |

|Method: Indicate the letter(s) in which each service will be provided to the child and family. There may be more than one method a service is provided. |

|Individual (I): service is provided on a one-to-one basis with the child, focusing on a specific areas of delay. |

|Group (G): service is provided in a small group setting with 2 or more children with a primary provider |

|Consultation (C): service/support is provided to a child/team periodically by an early intervention provider. The consultant must see the child, generally as a joint visit with the primary provider to observe how the child is|

|progressing and what additional support is needed by the primary provider and/or the family. |

|Primary Service Provider (P): The identified primary service provider supports the family in implementing the outcomes/objectives/strategies outlined in the IFSP with consultation from appropriate therapist(s). |

|Location: For each service, indicate where the service will be delivered using number 1-3. There may be more than one setting that a service takes place, therefore list each location, indicating frequency and intensity for |

|each location. |

| |

|1. Home |

|2. Community Setting |

|3. Other (Non-natural environment) |

| |

|Anticipated Duration: Indicate the length of time (month/day/year) that the team estimates a service will be provided. This does not have to be the exact date in which a service has started or ended. |

| |

|Start Date: Date in which a service is anticipated to begin. NOTE: If a staff person is not available and/or a FFS must be secured, the date entered should not be greater than 30 days from the IFSP date. Include a |

|notation on the IFSP meeting notes page that the program is in the process of hiring or whatever is discussed at that meeting. |

|End Date: Date in which a service is anticipated to end not to exceed the next Annual IFSP date or the child’s exit date. |

| |

|Actual End Date, if needed: For each service, indicate the actual date each service ended (month/day/year). |

| |

|Funding Source: If the family consents to bill their private insurance, put an * by the service and make a notation on the IFSP meeting notes page that private insurance may be billed for that service. |

OTHER ENVIRONMENT: If services were provided in “other environment” (not a natural environment), list reason(s) why other environment was selected.

| |

|Purpose: This section justifies any services that are not provided in the natural environment and ensures that the family is informed of their rights to receive services. |

| |

|A natural setting is one in which the child would spend with other peers who have no disabilities. This would include the home, family childcare, childcare center, preschool or other settings. If any service is not |

|delivered in a natural environment, you must complete this section and state why other environment was selected. |

VI. OTHER SERVICES None at this time                 (Date)

Purpose: This section identifies medical and other services that the child/family are currently receiving but are not mandated early intervention services under Part C of IDEA.

Note: “Other services” that have not yet been obtained should be listed as an outcome that includes steps that the care coordinator will take to assist the family in accessing such services.

|SERVICES |PROVIDER |FUNDING SOURCE |START DATE |END DATE |

| | | |(optional) |(optional) |

|List other child-related services that are in place but are |List pediatrician, name of agency, program, etc. |Indicate the funding or payment source for |Indicate month and year|Indicate end date of other|

|not required early intervention services under the Part C of | |each service, or the steps to secure funding.|of other related |related services. |

|IDEA. They should have been discussed with the family. Only| | |services. | |

|other services that are child related should be listed here. | |Funding source should be noted to ensure that| | |

|This is to provide a total picture of the child related | |family is aware that early intervention does | | |

|services for the family and physician on a single page of the| |not cover these services. | | |

|IFSP. | | | | |

| | | | | |

|Family may chose not to list all of their other services. | | | | |

|Check and date if family does not identify other services | | | | |

|needed. | | | | |

|Examples: Pediatric |Dr. Ryan Moore | | | |

| | |Private Insurance |December 2002 |Present |

|Food Supplement |WIC |State |December 2002 |Present |

|Child Care |Auntie Aloha’s Family Child Care |Family |September 2004 |Present |

VII. Family members and service provider(s) who provided input into the development of the IFSP

Purpose: This section identifies the IFSP team members and serves as a record of persons who participated at the IFSP meeting and persons whose input were sought for the meeting but were unable to attend.

NOTE: The Initial and Annual IFSP meeting must have a signature page. For a Review IFSP, any changes must have a date and initial. If a new signature page is used for the Review IFSP, then changes must be dated (no initials needed). The date must match the date of the signature page.

|I/We select | |to be my Care Coordinator. I/We agree to be Co-Care Coordinator(s): |YES | |NO | |

The parent/legal guardian selects the care coordinator and the name is indicated. Check “yes or no” to indicate if the family agrees to be a co-care coordinator(s). Include discussion and explanation of the role of a co-care coordinator. Explain that a parent agreeing to be a co-care coordinator does not diminish the responsibilities of the care coordinator.

Team Member Table

• Box for agency/address is optional. Complete all other boxes.

• Family can choose who will receive a copy of their IFSP. The parent/legal guardian must initial to indicate their consent to provide a copy of the IFSP and “N/A” for those not to receive a copy. In anecdotal notes, document when the IFSP was sent to those indicated.

• If not present, document how the member participated.

• If invited, but no response, document “invited – no response.”

NOTE: The interpreter is not an “active” team member as they do not provide input into the development nor implementation of the IFSP. Their role as interpreter should be noted on the IFSP Meeting Notes Page. If the interpreter has another role (e.g., the Interpret is a neighbor who provides support to the family), then that person may be included on the team as a family friend if the family chooses.

For example, the occupational therapist and speech language pathologist who evaluated the child attend the meeting and their names are listed and checked. The doctor, who was contacted by phone and provided input, has his name listed but did not attend and it is not checked off. The doctor who provided input during the meeting via conference call is listed and checked that he was present during the meeting. If the doctor wasn’t present and provided input via phone call other than the day of the IFSP meeting, check not present and indicate that doctor participated via phone.

|TEAM MEMBERS |POSITION/ROLE | |IF NOT PRESENT |AGENCY/ADDRESS (Optional) |PHONE # |Initial to |

| | |cheCK |HOW DID MEMBER PARTICIPATE | | |send IFSP |

| | |IF PRESENT |(e.g. phone, report, etc) | | | |

|Jack Sample |Father | |Father gave feedback to mom. |1520 Pensacola St., Hon., HI 96814 |521-5555 |Init. |

|Anna Smith |Care Coordinator |X | |Hawaii Child Development Center: 1350 S. King |983-6000 |Init. |

| | | | |St. #200, Hon., HI 96814 | | |

|Dr. Ryan Moore |Physician | |Medical Report |KMCWC: 1319 Punahou St. # 1000, Hon., HI 96826 |395-1403 |Init. |

|Betty Crocker |Teacher |X | |Hawaii Child Development Center: 1350 S. King |983-6000 |Init. |

| | | | |St. #200, Hon., HI 96814 | | |

|Sara Lee |Speech Language Pathologist |X | |Talking Express, One Keahole Pl., # 1302, Hon., |395-1403 |Init. |

| | | | |HI 96825 | | |

|Peter Joell |OTR, Evaluator |X | |KMCWC 1319 Punahou St., Hon., HI 96826 |983-4000 |N/A |

|Auntie Aloha |Child Care provider | |Invited – no response |11 Childcare Street, Hon, 96814 |521-5554 |Init. |

The “Family Rights” brochure and the “Family Educational Rights and Privacy Act” (FERPA) notification are to be discussed/explained AND offered to the family at every IFSP Meeting, including reviews. Parent/Legal Guardian initials to indicate that their rights and FERPA was explained to them and they accept or decline a copy of the Family Rights brochure and FERPA notice.

The parent/legal guardian signature indicates that they understand and agrees to the IFSP Plan. If CWS is the legal guardian and was not preset at the IFSP meeting, provide a copy of the IFSP and request that CWS (any staff authorized to sign e.g., Social Worker, Supervisor, etc.) review the IFSP and return the signature page (a fax of the signature page is acceptable so services can start; however the signature page with the original signature must be obtained). CWS should enter the date that the document was signed. NOTE: The Foster Parent cannot sign the IFSP unless there is an official document from CWS giving the foster parent the authority to sign legal documents such as the IFSP.

|My/Our rights and the Family Educational Rights and Privacy Act were explained to me/us AND: |

|I/We have received a copy of the Family Rights brochure for early intervention services. |Initials: |Yes | |Declined | |

|I/We have received a copy of the “Family Educational Rights and Privacy Act” (FERPA) notification. |Initials: |Yes | |Declined | |

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|This IFSP was completed with me/us. I/We understand what it means and consent to implementing the services described in this document. |

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|Parent/Legal Guardian Signature: | |Date: | |

|Parent/Legal Guardian Signature: | |Date: | |

VIII. IFSP MEETING NOTES: Every entry must be dated and the Parent/Legal Guardian must initial at the end of each entry.

Purpose: This section serves as a written record of discussion/decisions (action plans, concerns, explanations or changes regarding services for the child and family) that occurred at the IFSP meeting that cannot be documented elsewhere on the IFSP.

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|Date | | |

|Enter date of notation | | |

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|Example: | | |

|06-08-04 | | A Physical Therapy evaluation was recommended; however, the family has decided to wait and not do the evaluation at this time. INITIAL |

|06-13-04 | | CC met with the family. The family reviewed and approved the typed copy of the IFSP based on the IFSP meeting held on 06-08-04. INITIAL |

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NOTE: Every child/family must have an exit IFSP Review meeting unless the family declines the meeting.

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