Individualized Family Service Plan

Family’s IFSP

(Individualized Family Service Plan) • Cover Page contains identifying information on child & family. • Completed after each Eligibility Evaluation. Child’s Name: ______

Date of Birth: ______Gender: ______

Address: ______

______

Phone: Home______

______’s Work: ______

Email: ______

Change of Address: ______

Primary Language: _ Written in family’s natural or chosen language unless it is clearly not feasible to do so. An English translation of the child’s developmental profile and service delivery plan is available at the program site for coordination and program monitoring purposes. Universal & brochure available in Chinese, English, Haitian Creole, Khmer, Portuguese, Spanish Russian & Vietnamese.

Parent / Caregiver: ______Relationship: ___Spaces allow for the inclusion of multiple caregivers/family members, foster family, etc.

Parent / Caregiver: ______Relationship: ______

EI Professional responsible for implementation of the IFSP:

Service Coordinator: __Service Coordinator must be assigned at the time of the IFSP meeting or prior to the IFSP meeting. This is the primary person who will be in communication with the family and act as their liaison with the program ______Date Assigned: ______

Service Coordinator: ______Date Assigned: ______

IFSP Duration: From: ______To: ______Review Date(s): ______Duration should never be more than 1 year. Parent’s signature indicates the date IFSP begins and should never extend beyond the 3rd birthday.

The IFSP is a working document that outlines the Early Intervention services to be provided. The plan is developed collaboratively between families and professionals based on the findings of a multidisciplinary assessment and evaluation. The IFSP is developed within 45 days of referral. It should be reviewed every six months and revised each time eligibility is re-determined. It can be

MDPH - Universal IFSP July 2012 1 Child’s Name: ______Date of Birth: ______reviewed more frequently, and changes can be made at any time the family and program agrees it is necessary. The EI Service Coordinator is responsible for implementing the plan, preparing for ongoing IFSP meetings, and meeting federal timelines.

MDPH - Universal IFSP July 2012 2 Child’s Name: ______Date of Birth: ______FAMILY PAGE

Every family is different and has its own priorities, concerns, and resources. This is your family’s opportunity to tell other members of the team about your child and family, and your involvement with other community providers. The information on this page is confidential and will not be shared without your permission. This page should be completed each time eligibility is re-determined.

How would you describe your child and your family? What do you see as the strengths as well as the concerns and priorities of both your child and your family? • Required Component – Statement of child’s strengths & needs, statement of family’s perceptions of their concerns and priorities. • Listen to family. Help them to identify what it is they would like to achieve through EI. • Written from the family’s perspective. • Updated annually, at each annual IFSP meeting. Concerns and priorities change. • Document how information was obtained – parent interview, resource/needs scale, parent completed on own, etc

Are there medical or community services that your family receives?

• Identifies other services & community resources. Gives a more comprehensive picture of child and family needs. Service coordinator assists the family in accessing services and resources.

Are there medical or community services that your family needs?

Provide a description of the steps the Service Coordinator or family may take in obtaining those other services and resources (details may also be reflected on the Family Outcomes page under strategies).

Family Directed Assessment/Checklist/Interview Date: ______

Information Provided By: ______Date: ______

MDPH - Universal IFSP July 2012 3 Child’s Name: ______Date of Birth: ______DEVELOPMENTAL PROFILE

Required component: statement of child’s development and status in each of six domains – perceptual/fine motor, cognition, expressive/receptive language, social/emotional, self-care, gross motor. Includes vision & hearing. Completed annually. When a child is eligible via Clinical judgement an evaluation is required at 6 months.

The Child’s Developmental Profile (pg. 3 & 4) summarizes the assessment and evaluation results and information gathered about your child’s health and development. It may or may not include developmental levels depending on the desires of your family and other team members. This section is designed to be shared with insurance companies, physicians, schools, and others as designated by the parent(s)/guardian(s).

Date of Assessment and Evaluation ______Age of Child: yrs. ______mos. ______

Parent/Caregiver Name(s): ______

Eligibility Evaluation Instruments Used:

Early Intervention Developmental Profile (Michigan) Battelle Developmental Inventory – 2nd Edition

Other Assessment and evaluation Input:

Clinical Observation Parent/Caregiver Report Other: ______

PARTICIPANTS AND DISCIPLINES:

MEDICAL HISTORY / HEALTH STATUS:

• Clinical summary of child’s medical concerns & needs.

VISUAL AND HEARING STATUS:

SUMMARY AND RECOMMENDATIONS:

• Summarizes the multidisciplined assessment/evaluation utilizing DPH approved eligibility tool(s).

• Should include child’s learning style, where assessment took place, assessment environment & results of eligibility determination – eligible, not eligible, eligible under clinical judgement.

• Dev. Profile may or may not include functional levels depending on the desires of the family.

MDPH - Universal IFSP July 2012 4 Child’s Name: ______Date of Birth: ______• DO NOT WRITE SPECIFIC SERVICE DELIVERY OPTIONS under Recommendation: i.e. home visit by PT, child group 2x/week, etc. Recommendation – Child is eligible/team will work with family to address outcomes.

MDPH - Universal IFSP July 2012 5 Child’s Name: ______Date of Birth: ______DEVELOPMENTAL PROFILE (Cont.)

Date of Assessment and Evaluation ______Age of Child: yrs. ______mos. ______

Developed in response to families’ desires to have a page that focuses on area(s) of greatest need. May or may not include developmental levels.

Social Emotional/Personal Social/Interaction: • This page contains all information from eligibility evaluation. Format should be a short narrative. • Battelle Devel. Inventory is properly administered and scored. • Developmental score is a single number, not an age range. • The Development Profile will replace a separate assessment write-up.

Cognition:

Motor Development including Gross Motor and Fine Motor:

Adaptive/Self Care:

Communication including Expressive and Receptive:

MDPH - Universal IFSP July 2012 6 Child’s Name: ______Date of Birth: ______CHILD & FAMILY OUTCOMES AND STRATEGIES

This page outlines the specific measurable results, outcomes and strategies that have been developed with the family as part of the Early Intervention Team based on the concerns identified through the evaluation/assessment process and family priorities. The Service Coordinator should discuss with the family what they hope to achieve through their Early Intervention experience including pre-literacy and language skills, as developmentally appropriate, the degree to which progress toward achieving the results or outcomes identified are being made and whether modifications or revisions are necessary.

START DATE: ______

Desired Outcome – We want (what will happen or change?):

So That (why is this important?):

Activities & ideas we can do to make this happen (strategies):

Who will teach or learn to do these activities?

Places to teach and/or learn to do these activities:

We will know we are successful when (what will we observe or measure?) (Include a time frame):

Review Date: ______we accomplished this outcome we will revise this outcome we will continue this outcome

Describe the degree to which progress toward achieving the results or outcome has been made:

• Requirement: statement of major outcomes expected to be achieved for child & family.

• Avoid using a deficit model.

• Represents a combined effort of family & staff that outlines the specific outcomes based on concerns & priorities identified through the assessment/evaluation process & parent input. MDPH - Universal IFSP July 2012 7 Child’s Name: ______Date of Birth: ______• Outcomes reflect family concerns and priorities. Team & family develop strategies to meet those outcomes.

• Outcomes should support the child’s and family’s routines.

• Question to ask families: Are there areas you would like help or assistance in meeting the needs of your child?

• Avoid terms, “Increase,” “Decrease.” Instead of “Increase expressive language” – “John will learn 3 new words/signs for breakfast foods.” Strategies should incorporate caregiver, grandparents, etc.

• Outcomes need to be functional and measurable to the satisfaction of parents & professionals working together.

Services, e.g. PT are not strategies

MDPH - Universal IFSP July 2012 8 Child’s Name: ______Date of Birth: ______SERVICE DELIVERY PLAN

This page identifies the Early Intervention Services, based on peer reviewed research (to the extent practicable) that are necessary to meet the unique need(s) of the child and family to achieve the measurable results or outcomes. These services may include home visits, community child groups/EI only child groups, parent groups, transportation, specialty services, etc. The provider of each service should be identified by discipline; and the location should include natural settings such as home, child care settings, playgroups, and other community sites. Changes in specific Early Intervention services, frequency, or location requires parental consent, are recorded on the IFSP Review pages, and updated below. EI services are supported by the Department of Public Health through state and federal funds; Medicaid; private health insurance and fees for some families based on family size and income.

• THE TEAM (WHICH INCLUDES THE PARENTS) DETERMINES SERVICES TO ENHANCE THE CHILD’S DEVELOPMENT AND TAKES INTO CONSIDERATION SERVICES THAT WILL SUPPORT THE CHILD AND FAMILY ROUTINES. • Type of service is home visit, community child group, etc. as listed in EI Standards, not PT, Speech, etc. • Location describes where service will take place – home, community playgroup, etc. • Frequency describes how often. Avoid ranges – 1-4x/month. Avoid symbols & abbreviations not understood by family -- EOW. • Duration should be specific. Avoid ranges – 1 to 3 months. • End Dates are important! 1. Method/Intensity (individual or group)/Type of EI Service 2. Location Start 3. Length (of time) and Frequency(# of days/sessions) End Date 4. Duration (of service) Date 5. Method of Delivery (how and by whom) Service Provider/Discipline 1. Method/ Intensity/ 2. Location 3. Length/Frequency 4. Duration 5. Provider/Discipline Type of Service: Example: Home Visit Child care 1hr/1 x/wk 6 months Jane Jones/OTR

In what natural environments (where and with whom) will each service be provided? How will collaboration with individuals in these environments occur?

Individualized clinical justification on the IFSP for all EI services that do not occur in a natural setting (as determined by the parent and IFSP team) must include the following: An explanation of why the IFSP team determined that the outcomes could not be met in the child’s natural settings, an explanation of how services provided in this setting will support the child’s ability to function in his/her natural environment, and a transition plan with timelines.

MDPH - Universal IFSP July 2012 9 Child’s Name: ______Date of Birth: ______Definition of Natural Environment is part of the Federal Regulations. Refers to services delivered to infants and toddlers with disabilities in natural settings – those in which a child without disabilities would participate. What constitutes a N.E. for an individual child & family is determined by that family. Natural Environment is people, places, things that are reflected in Outcomes, not where we do EI but how we do EI. Intent is to provide family-centered, community based services which support the inclusion of all EI-eligible children in all aspects of their own community.

Individualized Clinical Justification on the IFSP for services that do NOT occur in natural settings must include the following three points: 1. An explanation of why the IFSP team determined that the child’s outcomes could not be met if the services were provided in the child’s natural setting with supports provided by the early intervention program. 2. An explanation of how services provided in this setting will support the child’s ability to function in his/her natural environment. 3. A transition plan with timelines and the supports necessary to allow the child’s outcomes to be satisfactorily achieved in his/her natural environment. Example:

Mary requires center-based early intervention services provided by a physical therapist in order to improve her balance and gross motor skills. She suffered a stroke in utero that has affected the right side of her body and impacts her strength and balance. By using the motor equipment available at the center, Mary can work on improving hip and ankle strategies and strengthening of these muscles. By working at the center with her parent present, activities can be carries over into her natural environment, i.e. stepping up and off a sidewalk curb, negotiating stairs, etc. EI team will reassess with parent in 3 months to determine the need for continued center-based visits.

MDPH - Universal IFSP July 2012 10 Child’s Name: ______Date of Birth: ______TRANSITION PLAN

EI services are available to eligible children until a child turns three, or until a child is determined ineligible. This page outlines the Transition Plan process that occurs before Early Intervention services end. Planning may begin at any time, but no later than when your child is 2 years 6 months of age. The process includes activities and tasks performed by the family and EI staff and should include a review of options for families, information for parents regarding the process of transition, support available to parents, information to be sent to the LEA and/or other community providers, and the specific plan for how the child will successfully transition to the next setting.

Start Transition Activities/Strategies Date

Provide explanation to family that transition planning activities occur for all children beginning at any time but no later than 30 months, and will be further discussed when appropriate.

General explanation of the limits of EI eligibility, i.e. until the child turns 3 or until the child is no longer evidencing a delay based on the Battelle Developmental Inventory

Identify the options available to the child and family in the community. (For example, public school, Head Start, child care, preschools, library story hour, Family Networks, parent-child programs, recreational activities etc.) What are the steps to further explore these options? Who will be responsible for these steps?

• Who’s going to do what? i.e., who will identify possible child care providers, etc. • Includes activities by both the parents and the staff.

Review training or informational opportunities available to parents on transition and future placements. These may include trainings and/or informational opportunities with school representatives offered through EI, the local Parent Advisory Council (PAC), Federation for Children with Special Needs Parent Training and Information Center, Family Networks etc.

Brochures, workshops, flyers other information about possible resources available to the family

Explore support options available to parents. These may include working with your Service Coordinator, Family TIES, PAC, parent-to-parent programs, public benefits or respite programs or other local, state and national resources.

MDPH - Universal IFSP July 2012 11 Child’s Name: ______Date of Birth: ______TRANSITION PLAN

Start Transition Activities/Strategies Date

Describe the steps and services to prepare the child for a transition. What will support the child’s adjustment or transition to a new program? (For example, visiting a new classroom or community setting, providing information to the new program, providing parents with information about early childhood development or community resources, etc.).

• Procedures to prepare the child for changes in service delivery.

Convene a transition planning conference. A transition planning conference is a meeting to review the child’s services, discuss possible program options with community providers, if applicable, and establish transition activities.

Must occur between 9 months and 90 days prior to the child’s 3rd birthday

A parent may choose not to refer to the Local Education Agency (LEA). They may Opt Out of notification to the LEA/State Education Agency (SEA) at 90 days prior to 3rd birthday.

I choose not to have personally identifiable information (my name, my child’s name, address, telephone number, and date of birth) sent to the LEA/SEA. No personally identifiable information will be sent to LEA/SEA unless consent is obtained to release information.

Parent/Guardian ______Date: ______

Transition Plan not completed for the following reason(s):

MDPH - Universal IFSP July 2012 12 Child’s Name: ______Date of Birth: ______TRANSITION PLAN

FOR CHILDREN REFERRED TO PUBLIC SCHOOL FOR SPECIAL EDUCATION OR RELATED SERVICES

There are specific activities and timelines to be followed when your child may be eligible for special education or related services according to Part C of the IDEA (34 CFR 303.209) This page outlines the steps and procedures that the EI program must follow.

Start Transition Activities/Strategies Date

Date of Referral/notification to the Local Education Agency (LEA): ______With a parent’s written consent, a referral must occur at least 90 days and up to 9 months prior to the child’s 3rd birthday.

Determine the information that will support the child’s transition. Written consent must be given before the EI program releases any information to the school system (for example, information from your child’s IFSP, evaluations/assessments, etc.)

IFSP (specify sections of IFSP to be sent):______Evaluations or Assessments Other Information: ______Notes:

Convene a transition planning conference. A transition planning conference is a meeting to review the child’s services, discuss possible program options with the LEA and establish transition activities. With parent’s permission, the LEA is notified and invited to this meeting.

Date TPC Invitation sent to LEA______

Date of Transition Planning Conference ______(known as the 90 day meeting with Local Education Agency (LEA). Federal Regulations allow the Transition Planning Conference to occur up to 9 months before a child’s third birthday.

Did the LEA participate in the Transition Planning Conference? Yes No

Notes:

Do not project date for TPC. The date listed should be the actual date of the meeting. TPCs are required for all children. The purpose of the conference is to inform the family about all possible transition options & to prepare family for termination of EI services. The TPC must include a discussion of concrete next steps and must be documented as a TPC on a contact note.

MDPH - Universal IFSP July 2012 13 Child’s Name: ______Date of Birth: ______REVIEW PAGE

Review Date: ______

Six-Month Review OR Complete

(A six month review or a complete review of the child’s progress related to outcomes & strategies, and service delivery of the IFSP must be multidisciplined and involve two or more individuals or professions, and one of these must be the service coordinator.)

IFSP Review Meeting A review of the IFSP for a child and the child’s family must be conducted every six (6) months or more frequently if conditions warrant or if the family requests a meeting to review the IFSP. The purpose of the periodic review is to determine the degree to which progress toward achieving the results or outcomes identified in the IFSP is being made and/or if modifications or revisions of the results, outcomes or early intervention services identified in the IFSP is necessary. The review may be carried out by a meeting or by another means that is acceptable to parents and other participants Summary of Discussion: • Distinguish between a Six Month review or a review of the entire IFSP. • IFSP Meeting Reviews of entire IFSP— must provide prior Notice of IFSP Meeting. • Designed to capture the ongoing discussion of changes in outcomes and service delivery, and provides documentation of prior notification and parental consent. • Informs family that they can request an IFSP meeting at any time with other team members. • Provide consent by agreeing to the plan OR agree to the plan with exceptions. • Includes place to note parent received Family Rights. Review of child’s developmental progress; Outcomes; Changes in Services, etc:

 Completed each time IFSP review takes place: o To document changes in service delivery o To document summary of discussion, who initiated review – Parent or Program Driven o To obtain parental consent for any change/modification/addition of IFSP  Any changes are updated on appropriate pages of the IFSP – i.e. change in service will be reflected on Service Delivery Page.  New Outcomes may be written directly on the Outcomes Page of the IFSP or Parents must give written on the review page and then updated in the IFSP consent before Early I/We have received the Individualized Family Service Plan Meeting Notice for an Intervention services can IFSP review meeting. begin. Parents may choose to give consent to some changes I/We have been informed of and received a copy of my family rights. I/We have in service and not others. Your participated in the development of this IFSP and: consent means that you have I/We agree to the changes in service described above. been made aware of any changes and that you agree to I/We consent for the program to access my public and/or private insurance for them. The IFSP services that a payment for any added early intervention service(s) noted above. parent(s) agrees to, subject to payment of the annual fee if applicable, must be provided.

I/We would like to have a complete IFSP Review Meeting with other team members.

I/We agree to the services in this plan with the following exceptions: ______MDPH - Universal IFSP July 2012 14 Child’s Name: ______Date of Birth: ______Parent Signature: ______EI Staff Signature(s):______

Parent Signature: ______EI Staff Signature(s):______

MDPH - Universal IFSP July 2012 15 Child’s Name: ______Date of Birth: ______ANNUAL SIGNATURE PAGE

This Signature Page must be completed in order to begin EI services. Participants in the development of the IFSP may include community representatives, extended family members, and others invited by the family. Once the IFSP document is signed please send/deliver a copy to the family. Please ensure the parent identifies that they have been given rights and accept services.

Parents must give written consent before early intervention services can begin. If the parents do not give consent for any early intervention service or if they withdraw consent after first giving it, that service will not be provided. The early intervention services that a parent agrees to, subject to payment of the annual fee if applicable, must be provided.

I/We have been informed of and received a statement of our rights during the IFSP development process and I/We understand that any services I/We accept will be provided.

I/We have received the Individualized Family Service Plan Meeting Notice for the IFSP meeting.

I/We have participated in the development of our IFSP and:

I/We accept the services described in this plan.

I/We consent for the program to access my public and/or private insurance for payment of early intervention services described in this plan.

I/We accept the services in this plan with the following exceptions:

Comments:

Document any areas of the Plan where the parents have concerns or may disagree.

SIGNATURES

Parent/Guardian ______Date ______

Other Team Members:

Service Coordinator ______Date ______

Other Team Member ______Date ______

Director (Optional) ______Date ______

MDPH - Universal IFSP July 2012 16