INDIVIDUALIZED FAMILY SERVICE PLAN

NAME:

DATE OF BIRTH:

AGE IN MONTHS:

CASE #:

____/____/______

______

_______________

ADDRESS:
LANGUAGE(S) CHILD HEARS MOST OF THE DAY:
PRIMARY PARENT/GUARDIAN NAME:

RELATIONSHIP TO CHILD:

ADDRESS:
PHONE (HOME):

PHONE (CELL):

LANGUAGE(S) SPOKEN/MODE OF COMMUNICATION:

OTHER PARENT/GUARDIAN NAME:

RELATIONSHIP TO CHILD:

ADDRESS:
PHONE (HOME):

PHONE (CELL):

LANGUAGE(S) SPOKEN/MODE OF COMMUNICATION:

MEETING INFORMATION:
Interim Initial 6 month Amendment Transition

PROJECTED REVIEW DATE:

____/____/______

IFSP TEAM MEMBERS ATTENDANCE

Please note that your signature reflects your participation at the conference and does not necessarily indicate
agreement or disagreement with the Individualized Education Program.
SPECIALTY / RELATIONSHIP
MEMBER'S NAME
SIGNATURE
TO CHILD

Primary parent / guardian

Other parent / guardian
Service coordinator

I received a copy of the early intervention procedural safeguards and due process procedures and an explanation
of this information.
I understand the procedural safeguards and due process procedures.
I participated in the review/change of the IFSP with the EDIS team.
I am in agreement with this review/change to the IFSP.
PRIMARY PARENT / GUARDIAN SIGNATURE

OTHER PARENT / GUARDIAN SIGNATURE

Page 1

NAME:

EI #:
_______________

AGE:
_______

DOB:
____/____/______

Conference date:
____/____/______

Present levels of performance

Communication: How your child understands and lets you know what he or she wants or needs.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Social/Emotional: How your child gets along with family members and other people.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Cognitive: How your child understands concepts and solves problems.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Adaptive: How your child performs tasks such as eating, dressing, bathing, toileting and sleeping.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Motor: How your child moves and uses his / her hands.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Family concerns and resources:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Page 2

NAME:

EI #:
_______________

AGE:
_______

DOB:
____/____/______

Conference date:
____/____/______

Outcome
OUTCOME:
SHORT TERM GOALS THAT SHOULD BE ACHIEVED IN ORDER FOR THE CHILD TO REACH THE
OUTCOME:

DESCRIBE WHAT CONSTITUTES PROGRESS TOWARD ACHIEVING THE DESIREDOUTCOME AND HOW
PROGRESS WILL BE MEASURED (I.E. OBSERVATION; PARENT REPORT; ONGOING ASSESSMENT; ETC.)

OUTCOME:
SHORT TERM GOALS THAT SHOULD BE ACHIEVED IN ORDER FOR THE CHILD TO REACH THE
OUTCOME:

DESCRIBE WHAT CONSTITUTES PROGRESS TOWARD ACHIEVING THE DESIREDOUTCOME AND HOW
PROGRESS WILL BE MEASURED (I.E. OBSERVATION; PARENT REPORT; ONGOING ASSESSMENT; ETC.)

OUTCOME:
SHORT TERM GOALS THAT SHOULD BE ACHIEVED IN ORDER FOR THE CHILD TO REACH THE
OUTCOME:

DESCRIBE WHAT CONSTITUTES PROGRESS TOWARD ACHIEVING THE DESIREDOUTCOME AND HOW
PROGRESS WILL BE MEASURED (I.E. OBSERVATION; PARENT REPORT; ONGOING ASSESSMENT; ETC.)

OUTCOME:
SHORT TERM GOALS THAT SHOULD BE ACHIEVED IN ORDER FOR THE CHILD TO REACH THE
OUTCOME:

DESCRIBE WHAT CONSTITUTES PROGRESS TOWARD ACHIEVING THE DESIREDOUTCOME AND HOW
PROGRESS WILL BE MEASURED (I.E. OBSERVATION; PARENT REPORT; ONGOING ASSESSMENT; ETC.)

Page 3

NAME:

EI #:
_______________

AGE:
_______

DOB:
____/____/______

Conference date:
____/____/______

Services
SERVICE

LOCATION:

SERVICE

LOCATION:

SERVICE

LOCATION:

SERVICE

LOCATION:

SERVICE

LOCATION:

SERVICE

LOCATION:

PROVIDED BY (DISCIPLINE)

DURATION
(minutes):

FREQUENCY:

START DATE:

END DATE:

____/____/______

____/____/______

PROVIDED BY (DISCIPLINE)

TYPE:*
DURATION
(minutes):

FREQUENCY:

START DATE:

END DATE:

____/____/______

____/____/______

PROVIDED BY (DISCIPLINE)

TYPE:*
DURATION
(minutes):

FREQUENCY:

START DATE:

END DATE:

____/____/______

____/____/______

PROVIDED BY (DISCIPLINE)

TYPE:*
DURATION
(minutes):

FREQUENCY:

START DATE:

END DATE:

____/____/______

____/____/______

PROVIDED BY (DISCIPLINE)

TYPE:*
DURATION
(minutes):

FREQUENCY:

START DATE:

END DATE:

____/____/______

____/____/______

PROVIDED BY (DISCIPLINE)

TYPE:*
DURATION
(minutes):

FREQUENCY:

START DATE:

END DATE:

TYPE:*

____/____/______

____/____/______

MINIMUM #
SESSIONS.

GROUP SIZE:**
MINIMUM #
SESSIONS.

GROUP SIZE:**
MINIMUM #
SESSIONS.

GROUP SIZE:**
MINIMUM #
SESSIONS.

GROUP SIZE:**
MINIMUM #
SESSIONS.

GROUP SIZE:**
MINIMUM #
SESSIONS.

GROUP SIZE:**

* Indicate type of service Individual Group Consultation Monitor **Only if service is provided in group setting
If any services provided in group settings without typically developing peers, explain why the IFSP team thinks this is appropriate:

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
If assistive technology device(s) are required, describe assistive technology device and purpose:
DEVICE:

PURPOSE:

COST:
DEVICE:

STAR DATE: ____/____/______ END DATE: ____/____/______

PURPOSE:

VENDOR

COST:

STAR DATE: ____/____/______ END DATE: ____/____/______

PURPOSE:

VENDOR

STAR DATE: ____/____/______ END DATE: ____/____/______

PURPOSE:

VENDOR

STAR DATE: ____/____/______ END DATE: ____/____/______

PURPOSE:

VENDOR

DEVICE:
COST:

STAR DATE: ____/____/______

VENDOR

DEVICE:
COST:
DEVICE:
COST:

END DATE: ____/____/______

Page 4