Individual Service Plan Sample PDF Details

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.

QuestionAnswer
Form NameIndividual Service Plan Sample
Form Length29 pages
Fillable?Yes
Fillable fields405
Avg. time to fill out29 min 26 sec
Other namesindividual service plan form, individual service plan, family self sufficiency program goals, tn ifsp

Form Preview Example

INDIVIDUALIZED FAMILY SERVICE PLAN

Child’s Name: _____________________________

IFSP Meeting Date: ______________________________________

Birthdate: _________________________________

IFSP Type: Initial

Annual

 

Designated Service Coordinator: __________________________

 

Service Coordinator Phone #: _____________________________

 

 

 

 

 

Date Due

Date Completed

Six Month Review

 

 

_________________

________________

Annual IFSP

 

 

 

_________________

________________

Additional Review Dated

 

 

_________________

________________

_________

_________

_________

_________

_________

_________

 

m/d/y

m/d/y

m/d/y

m/d/y

m/d/y

m/d/y

 

 

 

 

 

 

Date Due

Date Completed

 

 

 

Transition Dates

 

 

 

Notification of Local Education Agency (LEA) by age two.

 

_________________

________________

Planning Conference with Parent/s, Lead Agency, LEA and other Service Providers, as appropriate.

 

 

(At least 90 days, or up to 6 months prior to child’s third birthday)

__________________

________________

Transition to LEA, as appropriate.

 

 

__________________

________________

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

1

Page One: COVER PAGE

 

Enter

 

Child’s Name (first, middle, last)

IFSP Meeting Date – date of this meeting

Child’s Birthdate

IFSP Type – check if Initial or Annual

 

Designated Service Coordinator – name and agency

 

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: _____________________________________________________

 

 

Part C/TEIS/TIPS

 

 

 

DMR

 

 

CSS

 

 

From Tennessee’

 

 

 

 

 

 

 

 

 

 

 

Definition of Developmental Delay

 

 

 

 

 

 

 

Meets: (check if applicable)

 

 

 

 

 

 

 

 

Eligibility

 

 

 

 

 

 

 

 

 

 

 

 

 

% of Delay

 

¨

 

 

 

DMR ¨

 

 

CSS ¨

 

 

Diagnosed Condition

¨

 

 

 

 

 

 

 

 

 

 

Informed

Clinical Opinion

¨

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referral

 

 

 

 

 

 

 

 

 

 

 

 

 

m/d/y

 

 

 

 

m/d/y

 

 

m/d/y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source

 

 

 

 

Source

 

 

Source

 

 

 

 

 

 

 

 

 

 

 

 

DOCUMENTATION

 

 

 

 

 

 

 

 

 

 

IFSP Team Member – If present, sign

Agency/Title

Date

Contributed/

Fully

Area(s) of Concerns/

If not present, list member’s name

 

 

not present/method

Agree

Comments

(Service Coordinator

 

 

 

 

 

who organized this IFSP meeting)

 

 

 

 

 

(Parent)

 

 

 

 

 

(Parent)

 

 

 

 

 

(Evaluator/Assessor)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Designated Service Coordinator/Agency and Rationale

______________________________________________________________________________________________________________________________________________

 

 

 

_

 

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.

____________________________________________________________________________________________________________

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

By

 

 

Date

Chron. Age

(Adj. Age)

 

 

Strengths

I

Needs

 

 

I

 

 

 

I

 

 

 

I

 

 

 

I

 

 

 

I

 

 

 

I

 

Vision

By

 

 

Date

Chron. Age

(Adj. Age)

 

 

Strengths

I

Needs

 

 

I

 

 

 

I

 

 

 

I

 

 

 

I

 

 

 

I

 

 

 

I

 

Hearing

By

 

 

Date

Chron. Age

(Adj. Age)

 

 

Strengths

 

Needs

 

 

 

I

 

 

I

 

 

 

I

 

 

 

I

 

 

 

I

 

 

 

I

 

 

 

I

 

Physical Development-Gross Motor By

 

Instrument

Date

Chron. Age

(Adj. Age)

 

 

Strengths

I

Needs

 

 

I

 

 

 

I

 

I

I

I

I

Physical development/Fine Motor

By

 

Instrument

Date

Chron. Age

 

(Adj. Age)

 

 

Strengths

 

I

Needs

I

I

I

I

I

I

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)

By

Instrument

Date

Chron. Age

(Adj. Age)

 

 

 

Strengths

 

I

Needs

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

Cognitive Development

By

 

Instrument

Date

Chron. Age

(Adj. Age)

 

 

 

Strengths

 

I

Needs

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

Social/Emotional Development

By

 

Instrument

Date

Chron. Age

(Adj. Age)

 

 

 

Strengths

 

I

Needs

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

Adaptive Development

By

 

Instrument

Date

Chron. Age

(Adj. Age)

 

 

 

Strengths

 

I

Needs

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

Other

 

By

 

Instrument

Date

Chron. Age

(Adj. Age)

 

 

 

Strengths

 

I

Needs

 

 

 

I

 

 

 

 

I

 

 

 

 

I

 

I

I

I

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 family-directed assessment and the inclusion of the voluntary family-directed assessment information in the IFSP.

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 family—those things which are most important for the child and family.

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-directed assessment.

¨¨ Family agreed to the inclusion of the voluntary family-directed assessment in the IFSP.

Type(s)/method(s) of Family Assessment Used: _________________________________________________________________________________________________

Date(s) of Family Assessment:

_______________________________________________________________________________________________________________

Participants

______________________________________________________________________________________________________________________________

Family Resources

Family Priorities

Family Concerns

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filling out individual service plan sample step 1

The program will need you to complete the Revised, State, of, Tennessee segment.

Finishing individual service plan sample part 2

You need to emphasize the significant data from the Eligibility, of, Delay, Diagnosed, Condition, Informed Clinical, Opinion D, MR CSS, Referral, m, dy Source, m, dy Source, m, dy Source, DOCUMENTATION, Agency, Title and Date section.

Filling out individual service plan sample part 3

Please be sure to specify the rights and obligations of the parties inside the Parent, Parent, and Eva, lu, at, or, Assessor paragraph.

Filling out individual service plan sample step 4

Finalize by taking a look at the next areas and completing them accordingly: Name, Agency, Address, Phone, Rationale, Informed, Parental, Consent yes, no Parent, Parent, Date, Date, and Revised, State, of, Tennessee

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