IFSP Sample - EDN

Early Intervention Program
Student: Janie Smith Date Notice:
School: Demo Elementary School District: Demo District
Parents: Sally Smith
Initial IFSP
Child's Name: Janie Smith Phone:
Child's Birthdate: 2009-05-01 SSN: 222-77-7788
Age: 2 Medicaid# 999888333-12
Confidential
Referral to Early Intervention: where does this come from? Address: 222 East Second Street Pall, NE 65789
Family's Language Choice: Choose... Date of Consent for Evaluation: 10/26/2011
Additional Language Choice: None
Family would like an interpreter: Date MDT: 11/04/2011
Parent(s) / Guardian
1. Sally Smith Role: Parent
Home Phone: Work Phone:
Service Coordinator / Case Manager Information
Address: 222 East Second Street Pall, NE 68789
If you have any questions about this plan or any of the people working with your child, please call the person listed as the Services Coordinator / Case Manager.
Name: Sue Bainter Phone: 402-471-1860
Agency: Address:
IFSP Meeting Dates
Type Secondary Role Date Date Sent
Initial None 11/04/2011
IFSP Previous Meeting Dates
Type Date Date Sent
No previous meeting dates found.
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 1
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Previous IFSPs
No previous IFSPs to display.
Date Family Concerns And Desired Priorities
11/04/2011
Sally would like Janie to use more words and maybe even some phrases that are understandable to someone
outside of their immediate family.
Sally wants to take some night classes. She is not sure yet what she wants to do for a job.
Sally wants to use a Services Coordinator.
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 2
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Confidential
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Previous IFSPs
No previous IFSPs to display.
Date Familychild And Family Strengths
11/04/2011
Janie likes to be around other children and goes to the local daycare 3 mornings per week.
Janie likes to play with babies and her older sister's barbie dolls.
Confidential
Sally says that about a fewmonths ago, she could not understand anything Janie would say but could figure out what
she wanted by having Janie take her to what she wanted. She doesnt know why she can understand a few words
now, but no one else can.
Sally has made an appointment to talk to the local community college about possible coursework. Sally's Mom lives
nearby and Janie and the family see her often.
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 3
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Initial IFSP
Child's Present Levels of Development
Previous IFSPs
No previous IFSPs to display.
Date Vision - Date / Current Abilities
11/04/2011
Previous IFSPs
No previous IFSPs to display.
Confidential
Janie can see things across the room on the floor or table. She gets around the house and daycare safely. She sees
and recognizes pictures in books because she tries to say them.
Date Hearing - Date / Current Abilities
11/04/2011
Previous IFSPs
No previous IFSPs to display.
Janie passed her newborn hearing screen and Mom has no current concerns. Janie has only had one ear infection
and can hear Mom calling her from across the house or when she is upstairs.
Date Health/Status - Date / Current Abilities
11/04/2011 Janie has been very healthy. She recently got her H1N1 shot.
Previous IFSPs
No previous IFSPs to display.
Date Cognitive/Thinking Skills - Date / Current Abilities
11/04/2011
Janie likes to "take care" of babies and puts them in blankets. She pretends to feed them with a bottle. She also likes
to play with dishes and stacks them up as well as pretending to eat from them. Janie likes to do puzzles with her older
sister. She also likes to play barbies if her sister lets her. Janie loves books, especially ones about animals and brings
books to her family to read to her. She points to pictures and if Mom says the name, Janie will sometimes say
something that is not understandable, other times she smiles or laughs. She tries to make animal sounds too. Janie
follows routine directions from Mom and also will go to her room, the bathroom, to the car, etc. if she hears Mom or
another family member talking about it.
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 4
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Previous IFSPs
No previous IFSPs to display.
Date Communication Skills - Date / Current Abilities
11/04/2011
Previous IFSPs
No previous IFSPs to display.
Janie says a few words that mostly only Mom can understand: "da" for her name when asked, "dee" when asked how
old she is; also "owie", "mommy", "mama" (for gramma). She occasionally tries to put a couple words together "I ite"
for "I write", "ho baba" for "hold baby". Sometimes Janie will take Mom or another family member by the hand to show
what she wants but other times she gets frustrated and will cry or whine.
Date Social/Behavior Skills - Date / Current Abilities
11/04/2011
Previous IFSPs
No previous IFSPs to display.
Janie loves music and likes to dance to it. She can even hum some of her favorite songs. She likes to be outside and
chase the cat around. She plays well with the other children at daycare - usually this is alongside if in the house, but
also will do puzzles with other children her age or slightly older, or simple games. She also loves to go to Grandma's
house.
Date Self-Help/Adaptive Skills - Date / Current Abilities
11/04/2011
Previous IFSPs
No previous IFSPs to display.
Janie is a really good eater and usually eats just about anything that Mom gives her. She drinks from a regular cup
and uses silverware. She can undress herself and gets her pajamas on at night. She is very nearly potty trained and
has just started to tell Mom when she has to go "pe".
Date Fine Motor Skills - Date / Current Abilities
11/04/2011
Previous IFSPs
No previous IFSPs to display.
Janie likes to scribble on paper. She picks up small pieces of food using her thumb and index finger. She uses the
knobs on puzzles which are pretty small. She likes to color in her coloring book if her sister is doing this too.
Date Gross Motor Skills - Date / Current Abilities
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 5
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11/04/2011
Janie can kick a ball and tries to peddle on her big wheel. Sometimes she can and other times she might just push
with her feet. She runs, jumps, and climbs on furniture. She can go down the slide by herself at the park and likes to
swing.
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 6
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Goal #1
Goal / Outcome
Confidential
Janie will spontaneously use words and phrases during mealtime, while reading books, and when playing babies/Barbies with her
sister or other children at home and daycare. We will know she can do this when all family members and other children can
understand her words and phrases and she does not have to show them what she wants/means. This should happen at least once
per day at home and daycare.
Child / Family strengths and resources related to this goal:
Janie loves playing with babies when at home and daycare. She also likes to play Barbies with her sister.
Jamie likes to have books read to her and sometimes tries to repeat something she hears Sallysay after Janie has pointed to a
picture.
Janie has a few words and 2 word phases that are meaningful and Sallycan understand her.
Janie is a good eater and the family eats the evening meal together.
What will be done / by whom:
Sallyand daycare provider will:
* Be sure to talk about what they are doing in short words/phrases that match Janie's current level of communication.
* Offer Janie choices between things so that she can hear the words rather than trying to guess what she wants and asking
questions.
* Use Janie's interests to offer the opportunity for her to talk about what she likes.
* Repeat the words that Janie says, slowly and clearly so that Janie can hear what they sound like.
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 7
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Primary Coach (SLP) will:
* Come during high interest or high opportunity times of day to both the home and daycare, to discuss, model and brainstorm
about how to promote Janie's words by using books, play with babies, etc. as opportunities for Sally to model sounds for Janie
within the context of everyday language.
* Show Sallyand other caregivers how to use wait time when offering Janie a choice or the opportunity to say something, e.g. when
Janie points to a picture in a book, say "is that a puppy or a kitty?" and then reinforce anything she tries to say.
* Share progress observed and discuss next steps, invite Sally to include her observations in the GOLD assessment system.
* Help Sally and other caregiversapply successful strategies to other routines and learning opportunities.
* Be in contact with the early intervention team to participate in team meetings and receive coaching from the rest of the team.
Services Coordinator will:
* Participate in team meetings to provide updated information regarding the family.
* Be in contact with the family at least monthly to update the IFSP, record progress of outcomes, and assist in coordination of
resources to meet ongoing needs as identified by the family.
Progress will be reviewed every 3 months by family and PC through observation, family report
Plan Review for this Goal
Previous IFSPs
Date: Previous IFSP Text
How much progress :
Next Steps / Comments:
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 8
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Goal #2
Goal / Outcome
Sally will meet with the community college counselor and find at least one course to enroll in by January of 2012.
Child / Family strengths and resources related to this goal:
Sally has an appointment with the college already next month.
Sally's Mom is willing to help with taking care of the children depending on when the course(s) may be offered.
Sally will qualify for financial assistance.
What will be done / by whom:
Sally will:
* Think about what her interests are before the appointment at the college.
* Explorepossible courses and job/career possibilities.
* Fill out the paperwork for the financial assistance.
Services Coordinator will:
* Explain eligibility for use ofrespite funds to pay Grandma (Sally's Mom) if she watches the children.
Confidential
*Assist Sally in completing necessary paperwork to access funding resources and explore other options such as childcare if Sally is
not eligible for respite subsidy.
* Assist Sally in completing financial aid paperwork and any additional needs related to college enrollment.
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 9
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Progress will be reviewed every 3 months by
Plan Review for this Goal
Previous IFSPs
Date: Previous IFSP Text
How much progress :
Next Steps / Comments:
Are there special conditions for safe transportation for this child?
Car seat.
Service: Speech-language therapy
Setting: Home
Service: Services coordination
Setting: Home
family and Services
Coordinator
The Services that will be provided to support all goals and objectives are:
through
Family report and
enrollment in coursework
How Often? How Much? Group/Individual? Natural Environment?
12 days/6 month period 60 min/day Group and Individual X Yes No
When service Starts and Ends? Who pays? Who's Responsible?
11/04/2011 / 05/04/2012 School district Primary Service Provider
Include a justification of the extent, if any, to which a service will not be provided in a natural environment.
How Often? How Much? Group/Individual? Natural Environment?
1 days/month 30 min/day Individual X Yes No
When service Starts and Ends? Who pays? Who's Responsible?
11/04/2011 / 05/04/2012 Early Development Network Services Coordinator
Include a justification of the extent, if any, to which a service will not be provided in a natural environment.
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 10
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Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 11
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Initial IFSP
IFSP TRANSITION PLAN
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 12
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Team Members Present at the Meeting
Print Name Role Other Address and Phone
Sue Bainter Service Coordinator NDE Lincoln, NE 68509
PARENTS /FAMILY
Choose...
Confidential
Yes No I (we) understand the content of the IFSP and give consent for all services in the IFSP to begin unless indicated
below.
Yes No I (we) understand that a copy of the IFSP will be distributed within 7 calendar days.
PARENT / GUARDIAN SIGNATURE
Parent Signature 1 Parent Signature Date 1
Parent Signature 2 Parent Signature Date 2
(If 'No' selected above, please explain)
Any Comments:
Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739
NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 13
Parent Signature 1
Yes No
Parent Signature 2
Yes No
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Sig
on
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