Thecontentsoftheifsphavebeenfullyexplainedtome and If Iagreetotheservices,I
SECTION1:FAMILYCONSIDERATIONS-(Optional)
1.How would you describe your child? / The following would be helpful in the weeks or months ahead:
Meeting other families whose child has similar needs
Finding or working with doctors or other specialists
Coordinating your child's medical care
Finding out more about the services your family is receiving or could be
receiving
Finding new places to go in my community
Planning for the future
Transportation
Child Care
Finding someone to help out in my home (respite)
Housing. clothing, jobs, food, telephone
Safety
Finding a support group
Support/information for brothers, sisters, friends, relatives and/or others
Information about my child's needs
Help with insurance, SSI, Medicaid, Kid Care and/or DSCC
Recreation - fun things to do as a family
Other:
2.What are some great things about your family?
3. What are some things you find challenging or difficult?
4. Is there anything else you think would be helpful for others to know about
your child or your family?
Describe a typical day for your child and/or family:
Morning:
Lunchtime: / I'm concerned about and/or interested in my child's:
Moving, crawling and/or walking
Communicating
Learning
Feeding, nutrition
Having fun with other kids
Challenging behaviors or emotions
Sleep patterns
Equipment or supplies
Health or dental care
Pain or discomfort
Vision or hearing
Other:
Afternoon:
Dinnertime:
Evening:
Bedtime:
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.
I agree to provide this information
I do not agree to provide this information
Signature: Date:
(R11/2016)
Child’s Name: / EI #: / Date:SECTION 3: FUNCTIONAL OUTCOME #:
(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)
What do we want for 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 Intervention
and/or other
services and supports would
help us with this? / Fund Source / Upon review, how are we doing? Has our outcome been achieved? Should our outcome, strategies, activities
and/or services change? If so, how? Written parental
consent required to change any services.
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? Yes No
If no, justify the extent to which any services will not be provided in natural environments:
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: / EI #: / Date:SECTION7. IMPLEMENTATIONANDDISTRIBUTIONAUTHORIZATION / Requiredtoimplementservices
Thepurposeoftherequired"ImplementationandDistributionAuthorization"signaturepageis:1)tocertifythatthefamilyconsentsto the services outlined in the planimplementation and2)toindicatewhocan view or receivecopiesoftheplan, and who the family consents may exchange verbal/written information about the eligible child.
FOREARLYINTERVENTION (EI) PARTICIPANTSONLY
- ThecontentsoftheIFSPhavebeenfullyexplainedtome and if Iagreetotheservices,I understandtheymustbeprovided.
- IunderstandthatImayrefuseanyoralloftheservicesofferedbytheStatebutthatifIdo,mychildmaynotreceivethoseservices throughthePart C EI Program.
- IalsounderstandthatImayrequestdue process regardingtheservicesofferedandreceivetheundisputedservices whilethedisputeisbeingresolved,orifIalreadyhaveanIFSP,continuetoreceivetheservicescurrentlybeingprovided,whilethedisputeisbeingresolved.
- IunderstandandagreethatindividualPart C EI serviceproviderchangesmayoccurduringthecourseofservices, whichdonotrequireadditionalwritten consent on this page,aslongas,theservicetype,frequency,duration, andlocationare maintained.I do understand that a new signed consent to share the IFSP will be required for any new EI service providers not listed below.
- Inordertoimplementdeliveryofservices,IagreethatthisIFSPwillbedistributedtoEI serviceproviderslistedhereininadditiontotheindividuals/agencieslistedbelow.
- I consent to the verbal and written exchange of information between members of the IFSP Team.
- IunderstandthatthisIFSPmustbereviewedeverysix(6)months,ormoreoftenifnecessary.
- Finally,IunderstandthattheDepartmentofHumanServices,asleadagencyforthePart C EI Program,mayrefusereimbursementforservicesnotrequiredtobefundedbythe Part C EI ProgramandispayoroflastresortforallservicesrequiredtobefundedbytheState.Iherebywaivefurthernoticeregardingtheservicesagreedto.
IherebyconsenttoallEI servicesherein.
IherebyconsenttoallEI servicesherein,except:
Iherebyrefuseall EI servicesofferedherein.
Iconsenttothefollowingindividuals/agenciestoreceiveacopyofthisserviceplanandanyrevisionsmadetoit.
Name / Role / Address / Phone #
ParentorSurrogateParentSignature: / Date:
OtherSignature: / Relationship: / Date:
(R11/2016)
Child’s Name: / EI #: / Date:Date:
SECTION 8. MEETING PARTICIPANT/CONTRIBUTOR LIST / Date:
Date:
Initial Service Plan Meeting / Service Plan Review Meeting / 6 Month / Annual / Other
Name / Role . / Participated/Contributed / Name / Role . / Participated/Contributed
Service Plan Review Meeting / 6 Month / Annual / Other / Service Plan Review Meeting / 6 Month / Annual / Other
Name / Role . / Participated/Contributed / Name / Role . / Participated/Contributed
(R11/2016)