Child’s Name: Gabriella Smith DOB: 07/20/16 IFSP Start Date: 02/12/19

Idaho Infant Toddler Program

Individualized Family Service Plan – Part 1
Assessment and Planning Tool
The mission of the Idaho Infant Toddler Program is to provide quality early intervention support and
services to enhance the capacity of families to meet the needs of children birth to three years of age
who have developmental delays or disabilities.
We would like to begin by gathering some information about your child and family. This information will
be shared with your early intervention team and will help in making decisions about eligibility and
recommendations for possible services.
If your child is found eligible, this information will be used to develop the Individualized Family Service
Plan (IFSP). This information also serves as the Family Assessment.

Demographic Information
Child’s Name: Gabriella Smith Date of Birth: 07/20/16 Female ✔ Male

Parent/Guardian: Jennifer Smith Relationship: Mother

Address: 572 Taurus Drive City: Rexburg State: ID Zip: 83440

Phone Number: 512-574-7684 (w) (h) ✔(c) Email Address: jnsmith208@gmail.com

Phone Number: (w) (h) (c) (w) (h) (c)

2nd Contact: Relationship:

Address: City: State: Zip:

Phone Number: (w) (h) (c) Email Address:

Family’s Primary Language: English Child’s Race/Ethnicity: Caucasian

Additional Info (e.g. prefer text, directions): Prefer Text

Health Information
Primary Care Physician: Strategies 425 Medicaid #:

Clinic Name: Strategies 425

Address: 425 Strategies Way City: Rexburg State: ID Zip: 83440

Phone Number: 425-425-4252 FAX: Email Address:

Healthy Connections? Y N Insurance Company: Policy #:

Service Coordination Information

Service Coordinator: Agency:

Agency Address: City: State: Zip:

Phone Number: FAX: Email Address:

Intake Only Initial IFSP 6- Month Review Annual IFSP Date of Original IFSP:

Idaho Infant Toddler Program Date Completed 02/12/2019

Individualized Family Service Plan – July 2018
 Gabriella Smith 07/20/16 IFSP Start Date 02/12/19
Child’s Name: DOB:

Family Information
Please describe the concerns that brought you to the Infant Toddler Program:
Swallowing food, overwhelmed by flavor
Standing up getting leg straight and kneeling
Fine Motor
Sensory

Have you discussed this concern with your child’s doctor or other professionals? Please explain.
OT and PT. Discussed with several doctors.

What do you hope to see happen for your child and/or family within the next year as a result of your involvement
with the Infant Toddler Program?
Help swallow more food, over come sensory aversion mouth and touching things. STtrengtheing legs
sit to stand on own.

Child lives with: Mother and Father

Other Caregivers: Nurse, Grandparents, Aunts, Un cles  Foster Care
Child typically spends the day with: Mother and Nurse
Siblings / age: None

Pets: None
Other important people: Grandparents, Aunts, Uncles, Cousins
Additional important
Do not play with cousins often because they are not nice.
information:
Does child use or need any assistive
Wheel Chair, leg braces, feeding tube
technology like hearing aids,
orthotics, or positioning supports?

Medical Records/ Information Available:

HEALTH HISTORY □ Medical records
□ Medical/Social Report
□ Current Annual History and Physical Exam Date:
□ Dental, Hearing or Vision Providers:Strategies 425
□ Other Medical Providers: Strategies 425

□ Medications (name, dosage, frequency): Amlodipine, Zantac, Septra, Iron, Sulfate, Zyrtec, Multi-Vitamin
□ Other:

Please describe your child’s prenatal and birth history, birth weight/length, medical conditions, illnesses, injuries,
hospitalizations, immunizations, allergies, sleep patterns, etc. Is there a family history of physical or mental illness,
disability, vision or hearing loss?

Idaho Infant Toddler Program Date Completed: 02/12/19

Individualized Family Service Plan – May 2015
Mom indicate that Gabby was born at 37.5 weeks and that there was nothing unusual about the
pregnancy except for

Idaho Infant Toddler Program Date Completed: 02/12/19

Individualized Family Service Plan – May 2015
 Gabriella Smith 07/20/16 02/12/19
Child’s Name: DOB: IFSP Start Date

Related Resources:
CHILD/FAMILY ROUTINES & ACTIVITIES □ Interest-Based Everyday Activity Checklist
□ ABC Matrix □ RBI-SAFER Combo
□ SHoRE □ Other
What are the things your child enjoys most (including toys, people, places, activities, etc) or does very well?

puzzles, outside
Places- Park
People- All kdis

What does your family enjoy doing together and why? Who is involved? When does this occur?

Kidsburg- not super often. Summer- bear world season park, zoo. Just go to store and go down toy
isle. Mom and gabby or mom dad and gabby.

What activities/routines do you do throughout the day? How does your child participate? How satisfied with
the activities/routines are you?
On a typical day Gabby’s mother, Jennifer is the first one awake. Her mother or nurse will wait until 9am to wake Gabby up. She first gets off of her oxygen and then she is
tube fed. Her mother or nurse dresses Gabby. Some days during the week she will then have therapy, sometimes up the 3 times a week. Gabby plays in between her tube
feedings which take place up to 5x a day. Gabby’s mother bathes her every other day. Gabby hardly naps. Gabby is found to be more nauseous in the morning. Gabby does
not cry unless scared or in pain. Her mother indicated that Gabby is content through out most of the day.

Gabby’s mother works from home. There is a nurse at the Smith house from 8am-4pm, Monday through Friday. Gabby is fed up to 7 times a day to target her daily calories.
In between her feedings Gabby will read books, play or lay down, depending on how tired she is. When Gabby is being fed, she is sitting down typically watching a tv show
or playing with some simple toys.

Gabby goes to bed around 8-9pm. Gabby receives her medication at 8:30pm. Receives a feeding at 9pm. Her mother stated that if they plan it right Gabby will be asleep
before her 9pm feeding. Her mother is working on brushing teeth with Gabby. Gabby has a very strong gag reflex. Her mother does not know why. Her mother also indicated
that Gabby is overwhelmed by flavors. She will put some food in her mouth but it is typically crackers that are difficult for Gabby to swallow. Her mother indicated she wanted
Gabby to be able to swallow liquid food that is messy without gagging.
Are there any routines or activities that you find difficult or frustrating for you or your child? Or are there
activities/routines that your family is not currently involved in because of your child’s needs, but you are
interested in doing now or in the near future?
Not involved in toddler lab because of doctors appointments and surgeries
Swallowing/ Eating
frustrating hen she is offered more and doesn't want anymore. She gets antsy at restaurants because she is not eating and wants to get
on floor.

Are there times in which you find it difficult to soothe your child? What are you currently doing? Are you
interested in learning more about ways to soothe yourself or your child? (Refer to the Outcomes for Service
Coordination page for soothing strategies)
You have mentioned that Gabby is fairly content are there times. ... Bring in distractions. ex. at doctor in denver had
a study under machine she was scared. pull out cartoons and games without picking up. medical procedure can't
intervene in normal way.

Have you or your child participated in any of the following programs?

Present

Present

Present

Department of Health and Welfare Health Services Other

Past

Past

Past

✔ Medicaid ✔ WIC Nutrition Program Early Head Start or Head Start

Food Stamps ✔ High Risk Infant or Maternal Care Idaho Migrant Head Start
Financial Assistance ✔ Immunizations (Baby Shots) Indian Health Services
Home Care for Certain Disabled Family Planning Clinic ✔ EPSDT Well Child Check
✔
Children (Katie Beckett) ✔ Maternity Clinic ✔ Social Security
Child Protection Children’s Special Health Program IESDB
Personal Care Services ✔ Ages and Stages Questionnaires ✔ Children’s DD Services

Idaho Infant Toddler Program Date Completed: 02/12/19

Individualized Family Service Plan – May 2015
 Adult or Children’s Mental Health
Family Supports
Comments:

Idaho Infant Toddler Program Date Completed: 02/12/19

Individualized Family Service Plan – May 2015
 Gabriella Smith 07/20/16 02/12/19
Child’s Name: DOB: IFSP Start Date

Related Resources:
RESOURCE DEVELOPMENT □ Ecological Family Mapping (ECO Map)
Your family’s strengths and resources can support your child’s learning. To best serve your child, it is helpful to know
about issues or concerns that are important to you. You may share as much or as little family information as you choose.
What types of resources and supports can your family count on?
Nurse 5 times, Katie Becket Medicaid covers a lot of medical.

Do you have concerns about meeting the needs of your child or family within the next year?
If so,
 please check any items below that apply. Circle those that
 are of immediate concern:
 Physical (food, shelter, transportation, etc.) ✔ Educational (parenting/discipline, child development,
developmental disabilities, parent rights/safeguards,
Medical (vision, hearing, dental, immunizations and
transitions, English as a second language, obtaining GED,
 physical health)
 Vo-Tech, etc.)
Health & Safety (nutrition, feeding, environmental,
Personal (recreation, stress management, respite, legal,
 Child or Adult Protection, etc.)
etc.)

Therapy (adaptive equipment, assessments,
Long Range planning (changes that will occur, transitions,
 scheduling)
continued service coordination, etc.)

Social & Emotional (support groups, playgroups,
Financial/Benefits (income, bills, Medicaid, SSI, Katie
 nurturing, etc.)
Beckett, etc.)

Family needs and supports (how to communicate
 Translation / Interpretation services
about child’s disability, recreation, respite, counseling,
etc.) Other more things but with surgeries unable to do with toddler labs
Social Information – Psychological Stressors/Events (check all that apply within thepast year)
 
✔ Would you like information on
 Recent Death  Financial Difficulties
possible resources related to
Physical/Sexual/Emotional  Parent Separation/Divorce any items you’ve identified?
 Abuse  Change in Living Situation (refer to Outcomes for Service
✔ Recent Hospitalization
 Coordination page if relevant)
 Other (please describe)
 Custody/Placement Issues None
Child or Family Legal Issues
Please describe items checked above. Describe other resources about which you’d like more information:

Gabby has a diaphragm hernia and stomach hernia. Both of which she is receiving surgery for in the
next few months. She has to be hospitalized or visit the hospital to have check ups on her medical
diagnosis.

Idaho Infant Toddler Program Date Completed: 02/12/19

Individualized Family Service Plan – May 2015
 Gabriella Smith 07/20/16 IFSP Start Date 02/12/19
Child’s Name: DOB:

Description of Child
Present Level of Development (Information required for each domain)
Area of Other Data Sources
Parent/Caregiver Input
Development (Observation, Evaluation Results, Medical Records, etc.)

Recognizes letters, shapes, colours, Able to put puzzles together. Different

Cognitive – emotions "make them happy". varieties.
Thinking and learning
(ex., look for dropped toy;
pull toy on a string; do a
simple puzzle).

Communication - Understand language and express.

Expressive/Receptive
Talk in sentences. Undertsands talking
(ex., startle at loud noises; is a string of many words.
makes sounds; understands
sounds, words, gestures and
talking; uses two or more
word sentences; points to
desired objects).

Physical – Pick stuff up, scoot, move things. Can Scoots

Gross & Fine Motor/Sensory
(ex., reach for and play with
toes; sit, roll, crawl; throw a
small ball; thread cord
through large beads).
lace and bead things. Likes building
more than one block towers without
knocking it over. She can wheel herself
around.

Social/Emotional - Really good with children; a little shy Interacts with others.
Interacting with others around adults. Recently moved from
(ex., smile and coo; pull on being really scare in large groups of
your hand or clothes to gain
attention; share a toy; take
people.
turns with others).

Adaptive – Can't dress herself, but can put her Uses utensils but does not swallow.
Feeding, eating, dressing, arms through. Good sleeper, but only
and sleeping naps in the car.
(ex., help hold a bottle;
reach for a toy; help dress
himself or herself).

Vision/Hearing Screenings (Check those that apply)

Vision Hearing
Concern Y N Concern Y N
Screening Requested Newborn or Other Screening Requested
Screening Results: ■ Passed Referred Newborn or Other Screening Results: ■ Passed Referred
Date of Screening: 07/20/16 Date of Screening: 07/20/16
Screening Completed By: Stacy Screening Completed By: Stacy
Follow Up Needed: Follow Up Needed:

Idaho Infant Toddler Program Date Completed: 02/12/19

Individualized Family Service Plan – May 2015
Child’s Name: Gabriella Smith DOB: 07/20/16 IFSP Start Date: 02/12/19

Idaho Infant Toddler Program

Individualized Family Service Plan – Part 2
Plan Development

The development of an Individualized Family Service Plan (IFSP) is a process in which you
and your early intervention team work together as partners. Together we will create a plan
of action based on your family and child’s needs and assessments to support your family in
meeting your child’s developmental needs.

Child/Family Photo

Specialists from a variety of backgrounds and qualifications are available to work with and
support your family in promoting your child’s development and learning. The following people
are members of your early intervention team.

Name Role Agency/Address Phone Email

Jennifer Smith Parent

Kate Strategies Speech Therapist

Service
Sabrina Terry Coordinator
Holly Gibson Interventionsit
Dave Strategies OT
Megan Strategies PT

Early Intervention Team Photos (Optional)

✔ Initial IFSP Annual IFSP Date of Original IFSP:

Idaho Infant Toddler Program

Individualized Family Service Plan – July 2018
 Child’s Name: Gabriella Smith DOB: 07/20/16 IFSP Start Date: 02/12/19

Outcomes for Child

Now that we have identified your child’s interests and needs through the family and child assessments, we will focus on
what you would like your child to do.
Outcome # 1 What specifically do we want your child to do in the next few months? (Functional Outcome)

Do you know if there is any aspiration (choking or allowing food or liquid into the lungs) concerns with
feeding? Want to be able to swallow without gagging and throwing up. As far they know, no, but hasn't
been tested.

What is your child doing now? (Child’s current level of function related to this outcome.)

She can put food in mouth but it is difficult to swallow. Can swallow little sips of water.

The progress statement must be measured within the context of everyday learning activities.
How will we know we’re making progress? What will be different?
When do we hope to have this completed? (Progress Statement/Criteria for Success)

Progress through data collection. End of the semester

What strategies and resources will we use to make this happen?

(Who will do what during which regular activities and routines, and where will it occur?)

Where- home
Interventionists, mom, and maybe nurse.

Who will be involved? (Include names of all who will be involved)

Interventionists, mom, nurse, Interventionist will model the activity, teach parents, and then let the
parents work on the intervention throughout the week.

Review of Progress Statement/Criteria for Success

Date: 6 Month Annual Progress Achieved: We did it!
What Contributed to Progress? Lack of Progress? Continue: We are part way
there. Let’s keep going.
Discontinue: It no longer
applies.
Revise: Let’s try something
different.
Additional Comments:

New or Modified Outcome/Addendum Date: *Parent Initials:

*Parent’s initials indicate agreement with the changes noted on this page, but does not replace the signed Addendum SOS when required.

Idaho Infant Toddler Program

Individualized Family Service Plan – 12/15/17 Date Completed:
 Child’s Name: Gabriella Smith DOB: 07/20/16 IFSP Start Date: 02/12/19
Outcomes for Parent/Caregiver
This page documents what you and your family would like to achieve in order to support your child’s development.

Outcome # 2 What specifically do we want to accomplish? (Functional Outcome)

Standing up and getting leg straight. Strengthening leg.

What is happening now?

She can push self in bridge position. She can stand up next to the couch, but with assistance. She can
sit on something with leg straight but is not able to balance.

How will we know we’re making progress? What will be different? When do we hope to have this completed?
(Progress Statement/Criteria for Success)

Data collection, end of the semester.

What strategies and resources will we use to make this happen? (Who will do what during which regular activities and
routines, and where will it occur?)

Interventionist will model the activity, teach parents, and then let the parents work on the intervention
throughout the week. Balancing on a ball to strengthen leg.

Who will be involved? (Include names and phone numbers)

Review of Progress Statement/Criteria for Success

Date: 6 Month Annual Progress Achieved: We did it!
What Contributed to Progress? Lack of Progress? Continue: We are part way
there. Let’s keep going.
Discontinue: It no longer
applies.
Revise: Let’s try something
different.

Additional Comments:

New or Modified Outcome/Addendum Date: *Parent Initials:

*Parent’s initials indicate agreement with the changes noted on this page, but does not replace the signed Addendum SOS when required.

Idaho Infant Toddler Program

Individualized Family Service Plan – 12-15-17 Date Completed:
 DOB: 07/20/16 IFSP Start Date: 02/12/19
Child’s Name: Gabriella Smith

Outcomes for Service Coordination

Service Coordination is provided to all families enrolled in the Idaho Infant Toddler Program. A Service Coordinator will help your
child and family access resources and supports and will work with you to establish your Individualized Family Service Plan. This page
will outline steps and activities to assist you and your child as you move through the early intervention system.
Children and families participating in the program may encounter transitions at any point in time. Transitions are big changes that
occur in your family’s life. Service coordination outcomes should also describe transition activities that you and your family can
participate in over the next several months. Things like: bringing your child from the hospital to home, starting or changing a child care
provider, or moving to a new home.

Outcome # 3 What do we want to accomplish? (Desired Outcome) Start Date:

Kneeling but we would work on crawling with leg proper position first because crawling becomes first.
Target Date: 02/19/2019

Who will do what? (Strategies/Activities) Review Date:

Interventionist- crawling box. Interventionist will model the activity, teach Progress Code:
parents, and then let the parents work on the intervention throughout the Comments:
week.

Outcome # 4 What do we want to accomplish? (Desired Outcome) Start Date:

Pen control/ coloring. Hand in proper position and mark in targeted Target Date:
positions.
Who will do what? (Strategies/Activities) Review Date:
Interventionist will model the activity, teach parents, and then let the Progress Code:
parents work on the intervention throughout the week. Coloring a picture. Comments:

Outcome # What do we want to accomplish? (Desired Outcome) Start Date:

Target Date:

Who will do what? (Strategies/Activities) Review Date:

Progress Code:
Comments:

Strategies to soothe yourself and your child (optional): Start Date:

Comments:

Progress Review Codes: N = New C = Continue A = Achieved R= Revised D = Discontinued

New or Modified Outcome/Addendum Date: *Parent Initials:

*Parent’s initials indicate agreement with the changes noted on this page, but does not replace the signed Addendum SOS when required.

Individualized Family Service Plan – July 2017 Date Completed:

Idaho Infant Toddler Program

Individualized Family Service Plan – July 2017 Date Completed:

 Gabriella Smith 07/20/16 02/12/19
Child’s Name: DOB: IFSP Start Date

Plan for Transition from the Infant Toddler Program

The ITP must ensure a transition plan is established within a child’s IFSP no fewer than 90 days, and at the discretion of
all parties, not more than 9 months before a child turns three years of age. The transition plan must include steps for the
child with a disability and their family to exit from ITP.

As we think about your child’s participation with the Infant Toddler Program ending at age three, your hopes
and concerns are:

We are interested in learning more about and/or participating in community-based and other program options:
✔ Play group Library programs
Parks and recreation programs Head Start
Child care Private preschool
Medicaid Children’s DD program Transportation to programs
Therapy Services (Occupational, Physical, Speech-Language Pathology, etc.)
✔ Preschool special education through my local school district if my child is eligible
Other community programs:

School District Transition Timeline Dates

Projected Date
Transition Activities:
Start Date: Completed:
Notify school district and State Educational Agency of potentially eligible child 04/22/19
(no fewer than 90 days before child’s 3rd birthday, or as soon as possible if
determined eligible for Part C services between 45 days and 90 days before
child’s 3rd birthday)
Schedule and hold transition conference
(between 9 months and 90 days before child’s 3rd birthday) 04/22/01
Provide transition documentation at transition conference (obtain parental
consent) 04/22/01
School District Name/School Contact Name Contact Phone Number
District # Strategies 425 Mark Strategies 425-220-0425

What will help prepare our family and child for what’s next?
(visiting a program, parent training, assistance with applying for Medicaid DD services, transportation needs,
assistive technology needs, etc.)

What actions or activities? Who will help? When?

Idaho Infant Toddler Program

Individualized Family Service Plan – May 2015
 Gabriella Smith 07/20/16 02/12/19
Child’s Name DOB IFSP Start Date

Summary of Services Service Coordinator Signature:

Physician’s Recommendation Only Date:

Early Intervention Length (time service provided) Funding

Services Person(s)/ Start Date *NE
Frequency (# of days or sessions) Source
& Agency(ies) End Date
Method (how service provided)
Intensity (Duration) If Medicaid, Y or N
Responsible Location (place of service) MID #
(individual/group)

Physical Therapy Idaho Infant Toddler Program 12/2016

Occupational Therapy Idaho Infant Toddler Program 12/2016
Speech Therapy 5-6mo

*NE: If No, please complete the Natural Environment Justification page.

Other services the child or family needs or is receiving through other sources that are not required or funded
by the Infant Toddler Program (Part C of IDEA)

Diagnosis Description:

ICD-10 Code:

Consent by Parents/Guardians for Provision of Services

I participated in the development of this plan. I understand that:
 With receipt of my Procedural Safeguards, this plan serves as Prior Written Notice for evaluation, placement, and/or
the provision of listed services.
 If there is an increase in the frequency, length, duration, or intensity of services, a copy of the Infant Toddler
Program’s System of Payment policy will be provided and reviewed with me.
 The provision of listed services includes the completion of ongoing assessments.

I give informed consent for this Individualized Family Service Plan (IFSP) to be carried out as written.

Parent/Guardian Signature: Date:

Parent/Guardian Signature: Date:

Physician Recommendation and Financial Authorization
I have reviewed the above health-related services and certify that they are medically necessary and that continued care is necessary
for the duration of services listed in this Individualized Family Service Plan.

*Physician Signature: Date:

Physician Name (Printed or Typed): Clinic: _

I have reviewed and authorize payment for the above listed early intervention services as defined in the Individuals with Disabilities
Education Act (IDEA) Reauthorization, Public Law 108-446, Part C.

Lead Agency Authorizing Signature: _ Date:

Date of IFSP: Addendum / Date:

Initial Annual
6 Month review Reason for Addendum
Idaho Infant Toddler Program
Individualized Family Service Plan – July 2018
Idaho Infant Toddler Program
Individualized Family Service Plan – July 2018
 Gabriella Smith 07/20/16 IFSP Start Date
02/12/19
Child’s Name: DOB:

Justification for Services Outside a Natural Environment

Supports and services must be provided in settings that are natural or typical for children of the
same age. If, as a team, we decide an outcome cannot be achieved in a natural environment, we
need to describe why we made that decision and what we will do to move services and supports
into natural environments as soon as possible.

Early Intervention Setting

Outcome #
Services (Setting where service(s)/support(s) will be provided)

Explanation of Why Outcome Cannot be Achieved in a Natural Environment:

Plan and Timeline for Moving Service(s) and/or Support(s) into Natural Environments:

Projected Review Date:

Date of Review:
IFSP Team Participants (including Parents/Caregiver):
Holly Gibson, Sabrina Terry, Jennifer Smith, Gabby Smith

Recommendations:
Gabby is recommend for special education services under IDEA part c. She will began and contintue to
receive special services.

Idaho Infant Toddler Program

Individualized Family Service Plan – May 2015