Individualized Family Service Plan –
IFSP/ IFSP with Special Education Services
Status (check one): Early On® Referral Early On® Transfer With SESDate of Referral: / Date of Transfer:
Referral Source: / Transferred In From:
Child’s Legal Name: / Date of Birth:
Address of Child: / City: / Zip Code:
City of Birth: / Phone number:
Other phone or contact information:
Gender: FemaleMale / Ethnic Heritage: American Indian or Alaska Native Asian AmericanBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhite / Birth Order: / Child’s ID#:
Resident ISD: COP ESD / Resident Local District:
Family Member Name / Relationship to Child / Interpreter Needed? / Phone/ Alternate Contact
NoYes
NoYes
NoYes
NoYes
Address (if different from child):
CURRENT SERVICES/AGENCIES
Date / Agency / Contact Person / Phone
Service Coordinator: / Agency: COP ESD / Phone: 231 238-9394 x
Primary Physician: / Agency: / Phone:
Eligibility (check one): Not Eligible
Early On : Early On®Not EligibleSpecial Education / Developmental Delay: / Established Condition:
Special Education: / Sp. Ed. Rule #: Physical Impairment R.340.1709Other Health Impairment R.340.1709aSpeech and Language Impairment R.340.1710Hearing Impairment R.340.1707Vision Impairment R.340.1708Early Childhood Developmental Delay R.340.1711Severe Multiple Impairment R.340.1714Autism R.340.1715Cognitive Impairment R.340.1705Other, Specify: / Other:
Eligibility must be based on all 4 of the following (if not, explain):
Developmental History Health Status Observation of Parent and Child Developmental Evaluation
Comment:
IFSP Meetings: Dates:
Purpose: (interim IFSP, initial mtg, Initial IFSP, MET, Review, Annual, Redetermination, Transition Plan, Transition Conference)
Authorization to Share Information form signed
Child Outcomes
If initial IFSP meeting is not within 45 days from the referral: Family Circumstance Natural Disaster
Complete and attach: Permission to Evaluate form.
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FAMILY INPUTChild’s Name: / Person interviewed: / Date of interview:
What is your child’s typical day like? Who is he/she usually with? What does he/she play with?
On most days, what part of the day is the most enjoyable? The most difficult?
What people, supports or resources do you currently have? What resources would be helpful to your family?
What are some activities you enjoy doing with your child and family? What activities are stressful?
What are some of your child’s strengths?
What concerns do you have with your child?
Other family comments, observations, and questions:
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HEALTH STATUS/PARENT INPUTChild’s Legal Name: / Date of Birth: / Current Date:
*Child under 18 months- medical status within past 3 mos. Child over 18 mos. – medical status within past 6 mos.
Pregnancy/ Birth History:
Relevant Medical History/Diagnosis (w/ dates):
Child Primary Physician Address Phone/ Fax
Comments:
Attach input from Health Care professional.
Medications: / Allergies: / Adaptive Equipment: / Immunizations Up To Date?
Yes No
CHILD DEVELOPMENT
What Age Did Child:
Smile: Roll Over: Sit Up: First word: Walk: Other:
PRESENT LEVEL OF DEVELOPMENT as of (date)
Chronological Age: / Adjusted Age:
Area / Parent Input / Result of Developmental Evaluation / Agency/Tool/Date
Evaluator Name/Title / Family Priority
HEARING
See attached detail / Early On Chklist
AuDx screener
VISION
See attached detail / Early On Chklist
SureSight screener
COGNITIVE/THINKING
See attached detail / IDA Infant Toddler Ass’mt
COMMUNICATION
See attached detail
GROSS MOTOR
See attached detail
FINE MOTOR
See attached detail
SOCIAL/EMOTIONAL
See attached detail
SELF-HELP
See attached detail
Assessment held at Home Other. Present:
OBSERVATIONS – INTERACTION CHILD & PARENT/CAREGIVER
Comments and Observations:
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Early On IFSP Outcome and/or SES GoalChild’s Legal Name: / Date of Birth: / Current Date:
Present Level/ PLAAFP (What is the child doing now?):
Previous Services/ Interventions:
Goal/Outcome Statement (What would you like to see happen for your child?):
Goal #:
Steps or Short Term Objectives (at least 2 per goal): / * Evaluation / ** Criterion / Timeframe [EO]
Schedule [Spec Ed] see service page
1. / DPRAO DPRAO
2. / DPRA DPRAO
Strategies/Methods (What will be used during the child’s daily routines to meet this outcome?):
PROGRESS TOWARD OUTCOME
Note Progress - at least every 6 months Early On. 4x per year (including IFSP) for Special Education
Date / Objective / Status of Progress/ Comments ***
* Evaluation
D - Documented observation
P - Parent(s) report
R - Rating scale
A - Assessment Tool
O - Other / ** Criterion
___ % Accuracy
___ Achievement level
___ Other (specify) / *** Status of Progress
1 – Achieved/Maintained
2 – Progressing at rate sufficient to meet goal
3 – Progressing below a rate sufficient to meet goal ; needs revision
4 – Partially accomplished
5 – Other (specify)
MSE staff: Attach PLAAFP MET Offer of FAPE
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Service Plan Page, EARLY INTERVENTION SERVICESChild’s Legal Name: / Date of Birth / Current Date:
TYPE OF IFSP
Interim IFSP/ Date: Annual IFSP /Date:
Initial IFSP/ Date: Review IFSP / Date:
Review IFSP / Date: Transition Plan /Date:
Comments:
Services,
MSES Rule # / Supports Outcome # / How Long/How Often? (Visits/Hrs/Wk)
Method (Individual/Group) / Location
1 – Home
2 – Community Setting
3 – Other / Start Date/
Actual Start Dt. / End Date / Parent’s Initials / Funding Source
1.
1. Assistive Technology2. Audiology3. Family training, counseling, home visiting4. Health Services5. Medical Services6. Nursing Services7. Nutrition Services8. Occupational Therapy9. Physical Therapy10. Psychological Services11. Service Coordination12. Social Work Services13. Special Instruction14. Speech Language Pathology15. Transportation16. Vision Services
1. Assistive Technology2. Audiology3. Family training, counseling, home visiting4. Health Services5. Medical Services6. Nursing Services7. Nutrition Services8. Occupational Therapy9. Physical Therapy10. Psychological Services11. Service Coordination12. Social Work Services13. Special Instruction14. Speech Language Pathology15. Transportation16. Vision Services / , / /
2.
1. Assistive Technology2. Audiology3. Family training, counseling, home visiting4. Health Services5. Medical Services6. Nursing Services7. Nutrition Services8. Occupational Therapy9. Physical Therapy10. Psychological Services11. Service Coordination12. Social Work Services13. Special Instruction14. Speech Language Pathology15. Transportation16. Vision Services
1. Assistive Technology2. Audiology3. Family training, counseling, home visiting4. Health Services5. Medical Services6. Nursing Services7. Nutrition Services8. Occupational Therapy9. Physical Therapy10. Psychological Services11. Service Coordination12. Social Work Services13. Special Instruction14. Speech Language Pathology15. Transportation16. Vision Services / , / /
3.
1. Assistive Technology2. Audiology3. Family training, counseling, home visiting4. Health Services5. Medical Services6. Nursing Services7. Nutrition Services8. Occupational Therapy9. Physical Therapy10. Psychological Services11. Service Coordination12. Social Work Services13. Special Instruction14. Speech Language Pathology15. Transportation16. Vision Services
1. Assistive Technology2. Audiology3. Family training, counseling, home visiting4. Health Services5. Medical Services6. Nursing Services7. Nutrition Services8. Occupational Therapy9. Physical Therapy10. Psychological Services11. Service Coordination12. Social Work Services13. Special Instruction14. Speech Language Pathology15. Transportation16. Vision Services / , / /
Other notes and comments:
Natural environments means settings that are natural or normal for the child’s age peers who have no disabilities (34CFR303.18). The IFSP requires a “justification of the extent, if any, to which the services will not be provided in a natural environment” (IDEA section 636(d)(5) and (303.344(d)(ii). There must be a justification for each service not provided in the natural environment. Justification:
OTHER SUPPORTS AND SERVICES (Other resources, supports, services that assist the family)
To the extent appropriate, the IFSP must document services that are not required or covered under Part C. Listing the non-required services does not mean that those services must be provided, however, their identification can be helpful to the family and the service coordinator to assist in securing those services, including those through public or private sources.
Service/Support / Description
PARENT CONSENT (check all that apply)
I/We, as parent(s)/guardian(s), have had Early On® and Special Education explained to me/us including my/our rights and possibility of participation in an evaluation survey.
I/We have helped to develop this plan.
I/We understand and agree with its content.
I/We agree to each of the services I/we have initialed.
OR
I/We do not agree with this IFSP/ IFSP with Special Education Services.
I/We decline Early On®/ Special Education services.
Early On is required to provide you with this written notice of our offer of this plan, and you may take 7 days to consider this plan before signing it and beginning services. You may waive this seven day period if you wish.
Waiver of 7 Day waiting period. I understand that I am entitled to 7 days after receiving written notice before this plan takes effect. I choose to waive this timeline and begin implementing this plan before completion of 7 days. ______(parent initials).
Written prior notice was provided in parent’s native language, other mode of communication, or translated orally or by other means to the parent. Method used to communicate this information:. Date provided . Staff providing .
Parent(s) Signature: / Date:
Service Coordinator Signature: / Date:
Other Signatures, see reverse
TEAM MEMBERS AND CONTRIBUTORS
Printed Name and Role / Signature / Agency / Phone/Email
Parents
Service Coordinator
Lead Agency Rep.
LEA Representative
Early On® Consent to Evaluate Cheboygan Otsego Presque Isle -ESD
Child’s Name: / BD: / SS#:
Child’s Address: Phone #:
Early On® Michigan helps to make sure eligible children get the services they need to be healthy, grow, and develop their skills. Services to support children’s health, growth and development may come from many places in the Early On system. To find out whether or not your child qualifies for support or services from Early On, an evaluation of your child’s growth and abilities is conducted (i.e., how does your child think, see, hear, move, communication, relate to self/others, and take care of their basic needs).
During the evaluation, information about your child’s strengths, needs, health and development will be requested. You, your child’s doctor, and others who know about child growth and development will be asked to give information. Early On can only gather information about your child with your permission.
If you choose, you can share general information about your family including your resources, concerns, and priorities as they relate to supporting your child’s growth and development. If you choose not to talk about your family, your child will still receive services if he or she qualifies.
The information that is gathered from you or others is kept in your confidential Early On record. Basic information about your child will also be kept on a computer list of all children receiving services through Early On.
More information about Early On and about your family’s rights is in the Early On Family Guidebook, Parts 1-4, and on the reverse of this form. It is important for you to receive and understand these documents before you sign this consent form. The consent to evaluate is always voluntary. However, without an evaluation your child may not receive services under Early On.
Please put a check in the box for the statement that applies:
q I would like to learn if my child and family are eligible to participate in Early On Michigan:
Yes No I have received a copy of the following Early On information:
Welcome to Early On* ______q
Our Individualized Family Service Plan ______q
Transition: Leaving Early On ______q
Early On Family Rights* ______q
Yes No I have reviewed and understand the Family Guidebook and Family Rights
Information before signing this consent form, and prior to my child’s evaluation.
Yes No I understand my family’s role in the evaluation process.
Yes No I consent to the evaluation and assessment of my child’s abilities.
Yes No I consent to talk about my family’s resources, concerns and priorities related to supporting my child’s growth and development, and understand I only have to give information I am comfortable sharing.
Yes No I understand this consent form.
Early On is required to provide you with written notice of our request to do this evaluation at least 7 days before providing the evaluation. You may waive this seven day period if you wish.
Waiver of 7 Day waiting period. I understand that I am entitled to 7 days after receiving written notice before this evaluation takes place. I choose to waive this timeline and participate in the evaluation before completion of 7 days. ______(parent initials).
Written prior notice was provided in parent’s native language, other mode of communication, or translated orally or by other means to the parent. Method used to communicate this information: ______.
OR
q I do not wish to participate in Early On Michigan at this time.
- I understand that this means that my child will not be evaluated for Early On eligibility. I further understand that without consent and evaluation, an Individualized Family Service Plan (IFSP) will not be developed and we will not receive services available through Early On Michigan.
q I do not wish further evaluation by Early On Michigan at this time. ______(date and initial)
Signature of Parent: Date:
Signature of Witness: Date:
* Must be given at the first meeting; **May be given at first meeting along with “Welcome…” & Early On Family Rights
Procedural Safeguards
You have the right to request mediation or an impartial due process haring, or you may file a complaint should you disagree with the above proposed or refused actions. A copy of Early On Michigan Family rights is available at
You may request a copy of this document and/or ask for assistance in understating your right s by contacting your service coordinator and/or
If your child is also eligible for Special Education you will receive additional Procedural Safeguards information including contact information specific to your service area.
This notice was provided __ in person __ by mail __ by email
By: ______
Name Title Date Phone #
Review IFSP / Individualized Family Service PlanChild’s Legal Name: Birth Date: / Current Date:
Date of Review / Date of IFSP being reviewed
Be sure that a Review IFSP is appropriate. If necessary, complete an Annual (full) IFSP.
Please check all that apply:
“Review Progress” has been completed on IFSP Action Plan/ Outcomes page.
This review resulted in NO change to the IFSP dated
This review resulted in a change of personnel only:
Former person and role / New person and role, phone, agency
This review resulted in adding a new service or changing a service. Other services continue as previously written. A new Service Plan page is attached.
The “Authorization to Share Information” has been renewed for another six months.
Please complete and attach the new authorization form.
Comments:
Anticipated date of the next IFSP (Annual IFSP) is:
Notes: (Other relevant changes or comments):
Please sign below to indicate agreement. If review is done by phone, service coordinator sign and indicate ‘phone’ on line for parent/guardian.
Parent/ Legal Guardian ______Date ______Phone ____
Parent/ Legal Guardian ______Date ______
Service Coordinator ______Date ______
*Send this page and new “Authorization to Share Information” to agencies/ programs authorized to receive information and affected by the change.