A Individual Service Plan Sample Form is a written document that outlines the specific services and support that will be provided to an individual with a disability. It can help to ensure that both the individual and their service provider are clear about what is expected of them. This form can be used for both short-term and long-term goals, and should be reviewed and updated as needed.
In the list, there's some information regarding the individual service plan sample. You may want to learn its length, the actual time to fill out the form, the blanks you will have to fill in, etc.
Question | Answer |
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Form Name | Individual Service Plan Sample |
Form Length | 29 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 7 min 15 sec |
Other names | individual service plan template, sample isp plan, individual service plan examples, individual service plan form |
INDIVIDUALIZED FAMILY SERVICE PLAN
Child’s Name: _____________________________ |
IFSP Meeting Date: ______________________________________ |
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Birthdate: _________________________________ |
IFSP Type: Initial |
Annual |
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Designated Service Coordinator: __________________________ |
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Service Coordinator Phone #: _____________________________ |
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Date Due |
Date Completed |
Six Month Review |
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Annual IFSP |
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Additional Review Dated |
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m/d/y |
m/d/y |
m/d/y |
m/d/y |
m/d/y |
m/d/y |
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Date Due |
Date Completed |
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Transition Dates |
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Notification of Local Education Agency (LEA) by age two. |
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Planning Conference with Parent/s, Lead Agency, LEA and other Service Providers, as appropriate. |
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(At least 90 days, or up to 6 months prior to child’s third birthday) |
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Transition to LEA, as appropriate. |
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Natural Environments/Settings
To the maximum extent appropriate, services will be provided in natural environments, including the home, and community settings that are natural or normal for the child’s age peers who have no disabilities. Natural environments for young children are those environments/situations that are within the context of the family’s lifestyle – their home, their culture, daily activities, routines and obligations. Services will only be provided in settings not identified as the natural environment when it is determined that the desired outcome/s cannot be satisfactorily achieved within the natural environment of this child and family.
The natural environment for ___________________________ includes the following places/settings:
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Revised 6/22/98 State of Tennessee |
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Page One: COVER PAGE |
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Child’s Name (first, middle, last) |
IFSP Meeting Date – date of this meeting |
Child’s Birthdate |
IFSP Type – check if Initial or Annual |
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Designated Service Coordinator – name and agency |
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Service Coordinator’s Phone # |
Planned Six Month Review date and Annual IFSP date – enter the approximate Date Due and, later, enter the Date Completed (actual date the meeting was completed.)
Additional Review Dates – enter the actual date(s) of occurrence(s).
Transition Dates
Notification of Local Education Agency, Planning Conference, and Transition to LEA – enter the approximate due dates and, later, the actual dates completed.
Natural Environment/Settings
Enter the name of the child, and list or describe places and settings the team, including the family, has identified as natural environments for the child.
Page Two: IDENTIFYING INFORMATION
Enter Child’s Name, Birthdate, Social Security Number, Address, Phone Number. Enter Parent’s Name(s) – the natural or adoptive parent and Parent’s Address, if different from child’s.
Eligibility
Enter a check next to the Part C eligibility which indicates the Part C eligibility criteria the child meets (check only one.) If eligible for DMR and/or CSS, check the appropriate box.
Referral
Enter the date of referral and state the specific agency, professional, or person making the referral.
Documentation (To be completed at the end of the meeting)
All members of the IFSP team should
1.Sign (if team member contributed but was not present, see #4.)
2.Enter the agency/title of the team member.
3.Enter date – the date of the meeting.
4.If team member contributed/not present at the IFSP meeting, print the name in the signature column and describe the method of contribution (conference call, written input, telephone call, etc.)
5.If team member fully agrees with the IFSP, check under “Fully Agree.” If team member disagrees with part of the IFSP, use the space indicated to document area(s) of concern. Attach additional pages if necessary.
Designated Service Coordinator/Agency and Rationale
Enter the name of the person/agency the team selected and the rationale the team used in selecting this person.
Informed Parental Consent
Parent check the appropriate boxes (each must be checked yes.) Parent(s) signature indicates that procedural safeguards have been followed.
Revised 6/22/98 State of Tennessee
IDENTIFYING INFORMATION
Child’s Name:
________________________________________________
Child’s Birthdate: ___________ Child’s Social Security #:
_____________
Child’s Address:
______________________________________________
Street
City: _________________________ TN Zip:
______________________
Phone: ________________ County:
_____________________________
Parent’s Name(s): ____________________________________________
Parent’s Address (if different from child):
___________________________
Street
City: __________________________ TN Zip:
_____________________
Phone: _____________________________________________________
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Part C/TEIS/TIPS |
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DMR |
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CSS |
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From Tennessee’ |
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Definition of Developmental Delay |
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Meets: (check if applicable) |
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Eligibility |
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% of Delay |
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DMR ¨ |
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CSS ¨ |
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Diagnosed Condition |
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Informed |
Clinical Opinion |
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Referral |
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m/d/y |
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m/d/y |
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m/d/y |
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Source |
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Source |
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DOCUMENTATION |
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IFSP Team Member – If present, sign |
Agency/Title |
Date |
Contributed/ |
Fully |
Area(s) of Concerns/ |
If not present, list member’s name |
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not present/method |
Agree |
Comments |
(Service Coordinator |
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who organized this IFSP meeting) |
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(Parent) |
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(Parent) |
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(Evaluator/Assessor) |
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Designated Service Coordinator/Agency and Rationale
______________________________________________________________________________________________________________________________________________
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Name |
Agency |
Address |
Phone # |
Rationale |
Informed Parental Consent
yes no
¨¨ I am the parent/legal guardian/Department of Education trained surrogate parent of this child.
¨¨ I have been informed of & understand my rights as a parent in Tennessee under Part C Regulations. I have received a copy of Rights of Infants and Toddlers with Disabilities.
¨¨ I have participated in the development of the IFSP and understand its contents.
¨¨ I agree to its implementation to the degree noted above.
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Parent |
Date |
Parent |
Date |
Revised 6/22/98 State of Tennessee 2
Pages Three and Four: PRESENT LEVELS OF DEVELOPMENT
Record, next to the word “By,” the name of the professional(s) who conducted the formal or informal screening, evaluation, or assessment which provided the information for the present levels of development. Enter the Date of the procedure and the child’s Chronological Age at the time of the procedure. If the child was at least four weeks premature and under the age of two, enter the Adjusted Age. A narrative statement must be provided which records the strengths and needs of the child in each area of development. Test results should be reported in quantitative form (age level, percentiles, etc.). If the adjusted age is less than zero, the quantitative form of test results is not required.
Record the strengths and needs of the child in the developmental areas, based on professionally acceptable, objective criteria. This information, along with the family’s resources, priorities, and concerns, will be used in determining the major outcomes. The “Other” space may be used for any additional information, including the family’s assessment of the child’s present levels of functioning (especially if the family has chosen not to have a Summary of the Family Resources, Priorities, and Concerns discussed at the IFSP meeting.)
Revised 6/22/98 State of Tennessee
PRESENT LEVELS OF DEVELOPMENT |
Child’s Name |
___________________________
(Include a statement of functional strengths & needs in each area)
Health |
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Vision |
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Strengths |
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Needs |
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Hearing |
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Physical |
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Physical development/Fine Motor |
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Chron. Age |
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Strengths |
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Needs |
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Revised 6/22/98 State of Tennessee 3
Child’s Name ________________________
PRESENT LEVELS OF DEVELOPMENT (Continued)
(Include a statement of functional strengths & needs in each area)
Communication Development (Speech/Language) |
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Cognitive Development |
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Chron. Age |
(Adj. Age) |
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Needs |
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Social/Emotional Development |
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Adaptive Development |
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Chron. Age |
(Adj. Age) |
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Needs |
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Other |
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Chron. Age |
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Needs |
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Revised 6/22/98 State of Tennessee 4
Page Five: SUMMARY OF FAMILY RESOURCES, PRIORITIES, AND CONCERNS RELATED TO ENHANCING THE DEVELOPMENT OF THE CHILD
Information given in this summary is to reflect the Resources, Priorities, and Concerns of the family as identified by the family. The assessment is voluntary on the part of the family. The assessment should come from multiple sources which could include focused interviews, informal interviews, surveys.
Indicate, by checking wither “yes” or “no” in the statements at the top of the page, the family’s decision concerning participation in a voluntary
Enter the type(s)/method(s) of family assessment used, the date(s) that the family assessment(s) took place and the names of all who paricipated in the assessment process, including family members and professionals.
Enter in narrative or list form, a summary of
1.Family Resources that are available to the family, including formal and informal supports systems, educational resources, personal resources of family members (for example, the mother does not work outside the home and is very motivated to take her child and has time readily available to take her child to needed appointments, or the family is aware of their financial situation and is willing to accept financial help if it can secured.)
2.Priorities of the
3.Concerns of the family, including concerns the family has regarding their ability to cope with the child’s situation (for example, the family has a low income and is very concerned about its ability to pay for services their child needs.)
Revised 6/2/98 State of Tennessee
Child’s Name ____________________________
SUMMARY OF FAMILY RESOURCES, PRIORITIES, AND CONCERNS RELATED TO ENHANCING THE DEVELOPMENT OF THE CHILD
yes no
¨¨ Family agreed to a voluntary
¨¨ Family agreed to the inclusion of the voluntary
Type(s)/method(s) of Family Assessment Used: _________________________________________________________________________________________________
Date(s) of Family Assessment:
_______________________________________________________________________________________________________________
Participants
______________________________________________________________________________________________________________________________
Family Resources
Family Priorities
Family Concerns
Revised 6/22/98 State of Tennessee
5
Page Six: OUTCOME/ACTION STEPS
Major Outcomes
Based on information discussed prior to and during the IFSP meeting and documented on Page Two (Present Levels of Development) and on Page Three (Summary of Family Resources, Priorities, and Concerns Related to Enhancing the Development of the Child), the team (family and professionals) will identify major
Enter:
Major Outcome # The outcomes are numbered in the box for reference purposes only. Major
Johnny will eat table foods at family meals.
Ricky will learn to cruise in order to develop independent walking.
Mary will locate food placed in front of her in order to learn to feed herself.
Susan will find a child care center in order to provide adequate supervision of children enabling her to maintain a
Timeline (Target
Action Steps
List the steps, activities, strategies needed to achieve outcomes, for example:
Enter the name of the person(s) and agency responsible for each step, activity, or strategy.
Review/Changes
Review Status and Date are to be completed when reviews are completed and/or modification to the outcome is made with agreement by the family (and documented with a Review/Change form.)
Enter in the box beside review status the number which specifies the current status of the outcome. If a modification is made the outcome, enter the modification to the outcome or steps on the Review/Change Form. Comment is a brief statement or modification relating to the major outcome.
Revised 6/22/98 State of Tennessee
OUTCOME/ACTION STEPS
Child’s Name________________________
Major Outcome # _________________________________________________________ Timeline (Target Date) ________________
Action Steps
Person(s) Responsible
Review/Changes
Comment
*Review Status ___________________________________________________________________________________________ Date: _______________
m/d/y
*Review Status ___________________________________________________________________________________________ Date: _______________
m/d/y
*Review Status ___________________________________________________________________________________________ Date: _______________
m/d/y
*Review Status ___________________________________________________________________________________________ Date: _______________
m/d/y
*Review Status Key (1) on going (2) completed (3) delayed (4) unavailable (for
Revised 6/22/98 State of Tennessee
6
Page Seven: SERVICES
Enter
Services needed to achieve the outcome. These include services required by Part C and also additional services not required by Part C. Non- required services might include those provided through informal supports and/or community resources/services. Also list services (not required by Part C) that are needed but unavailable at this time.
Outcome
Provider
Required or
Starting
Expected
Review Date and Review
Enter
Review
Review
JUSTIFICATION FOR PROVISION OF SERVICE IN ENVIRONMENT/SETTING NOT IDENTIFIED AS THE NATURAL
ENVIRONMENT
If any of the above environments are not listed on Page One as natural for this child/family, complete this section.
Options
Complete the statement “The desired outcome could not be achieved in the natural environment because:” This will be the justification for the services not provided in the natural environment.
Revised 6/22/98 State of Tennessee |
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SERVICES |
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Justification for Provision of Service in Environments/Settings not Identified as the Natural Environment
Service:_________________ Options Considered _________________________________________________________________________________________
The desired outcome could not be achieved in the natural environment because:
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Service:_________________ Options Considered _________________________________________________________________________________________
The desired outcome could not be achieved in the natural environment because:
__________________________________________________________________________________________________________________________________
Service:_________________ Options Considered _________________________________________________________________________________________
The desired outcome could not be achieved in the natural environment because:
__________________________________________________________________________________________________________________________________
*Review Status Key (1) on going (2) completed (3) delayed (4) unavailable (or non0required services only) (5) modified
Revised 6/22/98 State of Tennessee
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Page Eight: OUTCOMES/SERVICES SUMMARY PAGE
In the left hand column of this page, list the Major Outcomes (by number and description) from Page(s) Six. Across the row, identify those Services to be Provided (required by Part C) to the child entering a “C”, those services to be provided to the family by entering an “F”, and those services which will provided to child and family by entering “CF.” Services which are required to be provided by Part C when needed are listed.
List other
Revised 6/22/98 State of Tennessee |
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OUTCOME/SERVICE SUMMARY PAGE (Optional) |
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Child’s Name_______________________________ |
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Services to be Provided (required by Part C) |
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Revised 6/22/98 State of Tennessee 8
Page Nine: REVIEW/CHANGE FORM
This is a multipurpose page. It is used to enter
1.Changes/additions to identifying information entered on Page Two.
2.Information if there is a change in the child status.
3.Information regarding an IFSP review/change.
Enter Child’s Name.
Enter Date of Current IFSP.
Enter Review
Enter a check under Review Type to indicate reason form is used.
Enter a check under Review Status to indicate the status of the IFSP.
Complete the box regarding Inactive Status if form is being completed to reflect inactive status (otherwise, do not complete.)
Enter the date when inactive status began. Circle one of the listed reasons for inactive status or specify “other” by giving a written description.
Enter reference of page/outcome#/service where changes/additions have been made.
Complete information regarding changes in outcomes or services as they occur.
Complete information regarding progress of outcomes at six month reviews or sooner if outcomes are completed.
This space may also be used to enter any changes to identifying information recorded on Page Two such as address, phone, parent.
Parent(s) check the appropriate boxes indicating their participation and approval and consent to the changes in the IFSP. Signatures of parent(s) and designated service coordinator are required.
Other IFSP Team Members Contributing to Review
Enter
Name (signature, if present, or printed, if not present, at time of review)
Title/Agency
Date contributed
Method of contribution (phone call, conference call, written review)
Revised 6/22/98 State of Tennessee
REVIEW/CHANGE FORM
Inactive Status ___________ Date inactive status began
no longer eligible
transition (Part B/Other) ________________________________________________
parent declined further service whereabouts unknown other (specify)
Enter reference of page/outcome#/service where changes/additions have been made.
Child’s Name _____________________
Date of Current IFSP________________
Review Date |
Review Type |
Review |
Status |
|
|
__________ |
_____six month |
_____continue |
IFSP |
|
|
|
_____parent request |
_____change |
IFSP |
|
|
|
_____provider request |
_____inactive |
IFSP |
|
|
yes |
no |
|
I have participated in the review of this IFSP. |
|
I approve the review status indicated and consent to |
|
the changes of outcome(s) and/or service(s) as |
noted |
in the IFSP. |
___________________________________________________________
ParentDate
___________________________________________________________
Parent |
Date |
Name
Other IFSP Team Member
Contributing to Review
Title/Agency |
Date |
Method |
|
|
|
________________________________________________
Designated Service Coordinator |
Date |
Revised 6/22/98 State of Tennessee 9
Pages Ten and Eleven: TRANSITION FROM PART C SERVICES PLAN
Enter
Today’s
Child’s Name
Date of Birth
Complete the Name of the Current Program and Type
Anticipated Date of
Planned Transitioning Procedures are those steps needed to insure smooth transition from Part C services to Part B or other services as appropriate.
Implementor is the name and agency of person(s) responsible for each of the steps listed. The Timeframe is the projected date the step is to be completed. The Date Completed is the actual date the step was accomplished.
This form will be copied and transferred to subsequent IFSP’s.
Revised 6/22/98 State of Tennessee
|
TRANSITION FROM PART C SERVICES PLAN |
|
Today’s Date ________________ |
|
Child’s Name _____________________________ |
m/d/y |
|
|
|
|
Date of Birth _________________ |
|
|
|
Current Program _______________________________ |
________________________ |
|
Name |
Type |
|
Anticipated Date of Transition: _______________ |
|
|
|
|
|
Planned Transitioning Procedures
Implementor
Timefram e
Date
Completed
Revised 6/22/98 State of Tennessee 10
Transition Plan (cont.)
Child’s Name ___________________________
Transition Page # ____
Planned Transitioning Procedures
Implementor
Timefram e
Date
Completed
Revised 4/7/98 State of Tennessee 11
IFSP CONFERENCE NOTES
Child’s Name ___________________________________
Date ________________
Revised 4/7/98 State of Tennessee 12
LEA_______________________________
PLANNING CONFERENCE
TRANSITION FROM PART C SERVICES
Child’s Name: _________________________________ |
Date of Conference: |
_________________ |
Child’s Address:_______________________________ |
|
m/d/y |
City:____________ State: ____ Zip: _____________ |
(No later than 90 days, and up to 6 months, prior to the child’s third birthday) |
|
Child’s Birthdate: _____________________________ |
|
|
Child’s Phone Number: ________________________ |
Note: Attach additional pages for notes or signatures, as needed |
|
Parent’s Name: _______________________________ |
|
|
Conference Notes: List/summarize activities discussed and/or planned to facilitate a smooth transition for this child and family from Part C Services
Conference Participants: (Signature)
Parent/s participation: (Signature)
_________________________________ Date ____________
_________________________________ Date ____________
I have participated in the decisions made during this Transition Conference.
I agree disagree with the decisions made at this meeting .
I have been informed of my Rights as a parent of a child with disability under Part B of IDEA.
Other Participants/Name |
Title |
Agency/LEA |
Date |
Designated Service Coordinator
LEA Representative
TEIS Representative
Other Agency Representatives
13
6/22/98 Please fax a copy of this completed document to the State Department of Education at
Planning Conference
Transition From Part C Services
Instructions
Required or Equivalent Form
Purpose: To document discussion and plans made at the transition meeting held 6 months to 90 days prior to the Part C eligible child’s third birthday.
Method: The designated service coordinator completes this form during the transition meeting or shortly afterwards. It is faxed to the Department of Education, Division of Special Education, Office of Early Childhood, where it is filed for monitoring purposes.
Directions:
1.Complete the identifying information regarding the child and family.
2.Complete the date the transition conference was held (90 days to 6 months prior to the third birthday.)
3.Summarize the discussion and plans made during the transition meeting. The complete transition plan is included in the IFSP.
4.Document the parent’s participation in the meeting and their agreement to the plans. Document that parents have received a copy of parental rights under Part B.
5.Document the other participants attendance at the transition meeting by signatures. At a minimum the participants consists of the parents, designated service coordinator, TEIS representative, who may also be the designated service coordinator and LEA representative.
6. Fax this form to the Department of Education following the conference.