Date:
Child’s Legal Name: / Birth Date:
Address of Child: / City:
Zip Code:
(check one) / Male Female / Child’s UIC#:
Child’s Ethnic Heritage:
Is the child Hispanic/Latino?
Yes No
/ Child’s Race: (Check all that apply)
American Indian or Alaska Native / Black or African American
Asian American / White including Middle Eastern
Native Hawaiian or Pacific Islander
Language of child considered for evaluation/assessment:
Resident ISD/RESA/RESD:
Resident Local District: / City of Birth:
Parent/Guardian Name / Relationship to Child / Native LanguageInterpreter / Phone: Day, Other/E-mail
neededprovided
neededprovided
Address if different from child:
Eligibility:
Part C: (check one) / Developmental Delay / Established Condition
Michigan Special Education list specific eligibility rule number (1705-1717):
Evaluated for Michigan Special Education and found ineligible.
Participating:
Yes / No
Part C:
Michigan Special Education :
Important Dates
Referral Date: / Referred by:
Interim IFSP Date: / Annual IFSP Date:
Including Transition Plan Including Transition Plan
Initial IFSP Date: / Periodic Review Date:
Including Transition Plan Including Transition Plan
Other Review Date: / Transfer Date:
Service Coordinator: / Phone:
Agency: / Address:
Justification for not completing the Initial IFSP Meeting within 45 days from the date of referral:
Parent/child is unavailable due to Exceptional Family Circumstances
Parent has not provided consent
Other (specify):
Explain the justification checked:
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Child’s Current Developmental Status / Date:
Child’s Legal Name: / Age: / Adjusted Age (for premature infants):
Date of Part C Multidisciplinary Evaluation: / Date of Michigan Special Education Multidisciplinary Evaluation:
Area / Present Levels of Development Including Strengths and Concerns (Developmental Evaluation/Ongoing Assessment) / Need for
Special Education Services / Method/Tool/Date
Person Completing the Area
Name/Discipline or Profession
Health
See Attached Report
Hearing
See Attached Report
Vision
See Attached Report
Gross Motor
See Attached Report
Fine Motor
See Attached Report
Cognitive
See Attached Report
Communication
See Attached Report
Social/Emotional
See Attached Report
Adaptive
See Attached Report
Developmental History
See Attached Report
Observation of Child & Parent Interaction
See Attached Report
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Family Directed Assessment
Resources, Priorities, and Concerns / Date:
Child’s Legal Name: / Person interviewed:
Interview conducted by: / Date of interview:
Early Intervention focuses on helping you help your child develop his/her everyday activities with your family. To best support your child and family, it is helpful to know the issues and concerns that are important to your family. Your family’s concerns, priorities, and resources related to enhancing your child’s development will be used as the basis for developing outcomes and identifying strategies and activities to address the needs of your child and family. This page is voluntary for the family.
Family Resources:
Family Concerns:
Family Priorities:
This information was gathered through a family-directed assessment using the following: (Check all that apply)
Family interview tool / Routines based assessment
Other tools:
Family declined family-directed assessment
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/ Individualized Family Service Plan - IFSP
Early On IFSP Child/Family Outcomes / Date:
Child’s Legal Name:
Present Status: (What is the child doing now? What has been tried? What is working?)
Measureable Outcomes: / Criteria / Procedures / Time frame
1.
2.
3.
4.
Notes: - Include, as developmentally appropriate, pre-literacy and language skills- Evaluate progress every six months
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Early Intervention Services / Date:
Child’s Legal Name:
Service / Frequency
(# of days/ sessions) / Length of Session / Service Delivery Method / Intensity
(Individual/ Group) / Location
1. Home
2. Community Setting
3. Other - Justify / Duration
(Projected
Start Date/
End Date) / Payor
1. / Justification below / ISD
LEA
2. / Justification below / ISD
LEA
3. / Justification below / ISD
LEA
4. / Justification below / ISD
LEA
5. / Justification below / ISD
LEA
There must be a justification for each service not provided in the natural environment.
Justification: Service # / :
Justification: Service # / :
Other Supports and Services
(Add other resources, supports, services that assist the family to the extent appropriate.)
Support/Service / Agency Providing Support/Service
and Frequency / Payment Arrangements
(identify potential funding) / Steps Taken to Secure Support/Service
(when applicable)
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Signature & Procedural Safeguards / Date:
Child’s Legal Name:
Team Members and Contributors
Printed Name and Role
☐Please check box if member
of evaluation team / Signature or Method of Participation / Participants / Phone/E-mail
Parent(s)
Parent(s)
Service Coordinator
Required for Michigan
Special Education:
ECSE Teacher/
Spec. Ed. Provider
MET Rep.
Lead Agency Rep.
LEA Rep.
I/We have received a copy of: (Please check all that apply)
I/We, as parent(s)/guardian(s), have had Early On, Part C and/or Michigan Special Education explained to me/us
including my/our rights.
I/We have helped to develop this plan. / I/We decline all services.
I/We understand and agree with the content of this plan. / I/We do not agree with this plan.
Parent(s) Signature: / Date:
Service Coordinator Signature: / Date:
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/ Individualized Family Service Plan - IFSP
Transition Documentation
Outcome: Successful transition out of Early On to new services/programs.
Child’s Legal Name: / Birth Date:
Present Eligibility for Special Education Services (check one) / Not Eligible / Eligible
Transition Plan / Plan Date:
Review program options after Early On ends:
Review services ending on Early On transition date. (see Early Intervention Services section of IFSP)
Review program/service options, if applicable, from the child’s third birthday to the end of the school year:
Step 1: Discussion with parents:
Step 2: Procedures to prepare child:
Transition services have been added to the Early Intervention Services page. (check if yes)
Transition Conference Participants / ConferenceDate:
Parent(s):
Service Coordinator:
LEA Representative (if applicable):
Other Participants:
Disposition of Early On Record / Transfer of Early On Information
Reviewed with parent(s) that:
-The IFSP record is maintained for a minimum of seven years.
-Notification is provided to the Local Educational Agency (LEA)/State Educational Agency of child’s potential eligibility for Part B special education services.
-Additional information,which may include the most recent evaluation/assessment and IFSP with parent consent, may be needed by the LEA to ensure continuity of services from Part C to Part B.
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/ Individualized Family Service Plan - IFSP
IFSP Review Page
Child’s Legal Name:
Progress Toward Outcomes
For determining progress toward achieving measurable outcomes and whether modifications or revisions are necessary.
IFSP Team Meeting Date / Measurable Outcome # / Progress on Criteria / Description of Modifications or Revisions Needed
Signature: / Date:
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