Individual Service Plan Sample – Fill Out and Use

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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).

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Transition Dates

Notification of Local Education Agency, Planning Conference, and Transition to LEA – enter the approximate due dates and, later, the actual dates completed.

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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.

______________________________________________________________________________________________________________________________________________

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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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.)

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(Include a statement of functional strengths & needs in each area)

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Child’s Name ________________________

PRESENT LEVELS OF DEVELOPMENT (Continued)

(Include a statement of functional strengths & needs in each area)

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.)

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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 outcomes—changes the family and the other members of the team would like to see for the child and/or family. Major outcomes may range from broad, long-term goals to short-range objectives. Major outcomes should be written in commonly understood language. An outcome should be written so that it could be used to determine whether the goal/objective was met. A separate page is to be used for each major outcome.

Enter:

Major Outcome # The outcomes are numbered in the box for reference purposes only. Major Outcome—for example

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 full-time job. David will smile and make vocalizations during play and care giving to show that he is happy, pleased, satisfied.

Timeline (Target Date)—the date by which the team hopes this outcome will be reached. This is usually one year but may be less than one year but no more.

Action Steps

List the steps, activities, strategies needed to achieve outcomes, for example: --have feeding assessment

--refer to and participate in feeding therapy if recommended by feeding assessment --Susan will obtain a list of possible child care centers from friends and DHS --home base interventionist will provide information to family on feeding strategies

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) ________________

Outcome #(s)--the reference number for the major outcomes.

Provider name--the agency or person recommended to provide the service.

Required or Non-required--enter an “R” if the service is required by Part C or an “N” if the service is not required by Part C--see listing of required services on Page Eight (Outcome/Service Summary Page.)

Starting Date--the date on which the service is scheduled to begin.

Expected Duration--approximate length of time (weeks/months or actual date) that the service is expected to last. Environment--in which the service is to be provided.

Frequency--the number of sessions scheduled each week or month, whichever is most appropriate. Do not use “TBD” or “to be determined.” Intensity--the length of time a service is provided during each session and whether it is provided on a group or individual basis.

Payor--by whom or how the provider will be compensated. Part C funds should be used only as a “last resort” after all other resources have been accessed.

Review Date and Review Status--columns are to be filled in when reviews are completed and/or modifications to the services are agreed upon (and documented with a Review/Change Form.) Add the service(s) from the Review/Change Form to this page.

Enter

Review date--the date on which the review took place.

Review status--use the status key at the bottom of the page and enter the appropriate number.

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.

Service--the required service listed above that is not being provided in the natural environment.

Options Considered--the environments/settings that were identified by the family and team as natural environments/settings and were considered by the team as possible environments for service delivery.

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.

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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 Non-Required Services which have been identified as beneficial to the child and/or family in the spaces provided.

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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 Date—the date this form was completed. Also enter the review date on the Cover Page.

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)

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Pages Ten and Eleven: TRANSITION FROM PART C SERVICES PLAN

Enter

Today’s date—the date that the transition plan is being developed.

Child’s Name

Date of Birth

Complete the Name of the Current Program and Type (home-based, child care, DMR center, physical therapy, etc.)

Anticipated Date of Transition—the child’s third birthday.

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.

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IFSP CONFERENCE NOTES

Child’s Name ___________________________________

Date ________________

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LEA_______________________________

PLANNING CONFERENCE

TRANSITION FROM PART C SERVICES

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)

6. Fax this form to the Department of Education following the conference.