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 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 Service Coordination Assessment.
Demographic Information
Childs Name: Date of Birth:

Female

Male

Parent/Guardian: Relationship:
Address: City: State: Zip:
Phone Number: (w)

(h)

E-mail Address:

(c)

Additional Phone Numbers:(w)

(h)

(c)

: (w)

(h)

(c)

2nd Contact: Relationship: Address: City: State: Zip:

Phone Number: (w)

(h)

(c)

E-mail Address:

Family Primary Language:

Health Information
Primary Care Physician:

Medicaid #:

Address: City: State: Zip:

Phone Number:

Email Address:

Healthy Connections? Y

Insurance Company:

Policy #:

Service Coordination Information

Service Coordinator:
Agency Address:
Phone Number:

Agency:

City: State: Zip:

Email Address:

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

Family Information
Please describe the concerns that brought you to the Infant Toddler Program:

Have you discussed this concern with your childs doctor or other professionals? Please explain.

What do you hope to see happen for your child and/or family as a result of your involvement with the Infant
Toddler Program?

Child lives with:

Other Caregivers:

Relationship:

Child typically spends the day with:

Siblings / age:

Pets:

Other important people:

Foster Care

Additional important information:

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

Additional Information Available:

HEALTH HISTORY

Medical records
Medical/Social Report
Other:

Attached

In Perm File

Please describe your childs prenatal and birth history, 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

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

CHILD/FAMILY ROUTINES & ACTIVITIES

Related Resources:
Interest-Based Everyday Activity Checklist
ABC Matrix

What are the things your child enjoys most (including toys, people, places, activities, etc)?

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

Are there any routines or activities that you find difficult or frustrating for you or your child?

Are there activities/routines that your family is not currently involved in because of your childs needs, but you
are interested in doing now or in the near future?

Medicaid
Food Stamps
Financial Assistance
Home Care for Certain Disabled
Children (Katie Beckett)
Child Protection
Personal Care Services
Intensive Behavioral Intervention
Adult or Childrens Mental Health
Family Supports

WIC Nutrition Program

High Risk Infant or Maternal Care
Immunizations (Baby Shots)
Family Planning Clinic
Maternity Clinic
Childrens Special Health Program
Ages and Stages Questionnaires

Comments:

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

Present

Health Services

Past

Past

Department of Health and Welfare

Present

Present

Past

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

Other
Early Head Start or Head Start
Idaho Migrant Head Start
Indian Health Services
EPSDT Well Chiild Check
Social Security
IESDB

RESOURCE DEVELOPMENT

Related Resources:
Ecological Family Mapping (ECO Map)

Your familys strengths and resources can support your childs 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?

Do you have concerns about meeting the needs of your child or family?
If so, please check any items below that apply. Circle those that are of immediate concern:
Physical (food, shelter, transportation, etc.)
Medical (vision, hearing, dental, immunizations and
physical health)
Health & Safety (nutrition, feeding, environmental, Child
or Adult Protection, etc.)
Therapy (adaptive equipment, assessments, scheduling)
Social & Emotional (support groups, playgroups,
nurturing, etc.)
Family needs and supports (how to communicate about
childs disability, recreation, respite, counseling, etc.)

Educational (parenting/discipline, child development,

developmental disabilities, parent rights/safeguards, transitions,
English as a second language, obtaining GED, Vo-Tech, etc.)
Personal (recreation, stress management, respite, legal, etc.)
Long Range planning (changes that will occur, transitions,
continued service coordination, etc.)
Financial/Benefits (income, bills, Medicaid, SSI, Katie
Beckett, etc.)
Translation / Interpretation services
Other

Please describe items checked above:

Are there other resources about which youd like more information?

Additional Notes:

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

Ecological Mapping
1. Each member can be represented by a color that they have chosen.
2. Document relationships and supports.
3. Activities that the family does together can be depicted by another color
that will extend from the center of the circle to the activity outside the circle.
(Please see supplemental document for instructions and examples)

Lines joining the circles show connections:

Male = Female =
Strong connection
Weak connection - - - - - - - Stressful connection
Energy flow into and/or out of family
unit or individual

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

Description of Child
Present Level of Development
Area of
Development
Cognitive
Thinking and learning
(ex., look for dropped toy; pull
toy on a string; do a simple
puzzle).

Communication Expressive/Receptive
(ex., startle at loud noises;
makes sounds; understands
sounds, words, gestures and
talking; uses two or more
word sentences; points to
desired objects).

Physical
Gross & Fine Motor/Sensory
(ex., reach for and play with
toes; sit, roll, crawl; throw a
small ball; thread cord through
large beads).

Social/Emotional Interacting with others

(ex., smile and coo; pull on
your hand or clothes to gain
attention; share a toy; take
turns with others).

Adaptive
Feeding, eating, dressing,
and sleeping

Parent/Caregiver Input

Other Data Sources

(Observation, Evaluation Results, Medical Records, etc.)

(ex., help hold a bottle; reach

for a toy; help dress himself or
herself).

Vision/Hearing Screenings (Check those that apply)

Vision
Concern Y
N
Screening Requested
Screening Results:
Passed
Date of Screening:
Screening Completed By:
Follow Up Needed:

Referred

Hearing
Concern Y
N
Newborn or Other Screening Requested
Newborn or Other Screening Results:
Passed
Date of Screening:
Screening Completed By:
Follow Up Needed:

Eligible for ITP Services?:

Yes

No

Date

Eligible for Childrens SC?:

Yes

No

Date

Comments:

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

Referred

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 family
members and service providers work together as partners. Together we will create a plan of
action to support your family in meeting your childs 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 childs development and learning. The following people are members
of your early intervention team.
Name

Role
Parent

Agency/Address

Phone

Email

Service
Coordinator

Early Intervention Team Photos (Optional)

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

Outcomes for Child

Date of IFSP:
Initial
Annual

Addendum / Date:
Updated Progress Statement / Date:

Now that we have identified your childs interests and needs we will focus on what you would like your child to do.

Outcome #

What specifically do we want your child to do in the next few months? (Functional Outcome)

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

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

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

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?)

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

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

How did we do? (Review of Progress Statement/Criteria for Success)

Date:

Date: Achieved: We did it!

Comments:

Date: Continue: We are part way there. Lets keep going.

The situation has changed:
Date: Discontinue: It no longer applies.
Date: Revise: Lets try something different.

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

Outcomes for Parent/Caregiver

Date of IFSP:
Initial
Annual

Addendum / Date:
Updated Progress Statement / Date:

This page documents what you and your family would like to achieve in order to support your childs development.

Outcome #

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

What is happening now?

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

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

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?)

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

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

How did we do? (Review of Progress Statement/Criteria for Success)

Comments

Date: Achieved: We did it!

Date: Continue: We are part way there. Lets keep going.
The situation has changed:
Date: Discontinue: It no longer applies.
Date: Revise: Lets try something different.

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

Date:

Outcomes for Service Coordination

Date of IFSP:

Initial

Annual

Addendum / Date:

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. This page will outline steps and activities to assist you and your child as you move
through the early intervention system.

Outcome #1

What do we want to accomplish? (Desired Outcome)

Start Date:
Target Date:

Who will do what? (Strategies/Activities)

Review Date:

Outcome #

Start Date:
Target Date:

Progress Code:N
Comments:

What do we want to accomplish? (Desired Outcome)

Who will do what? (Strategies/Activities)

Review Date:

Outcome #

Start Date:
Target Date:

Progress Code:N
Comments:

What do we want to accomplish? (Desired Outcome)

Who will do what? (Strategies/Activities)

Review Date:
Progress Code:N
Comments:

This box outlines what steps the family can take in an emergency.
Emergency Contact Plan:

Review Date:
Progress Code: N
Comments:

Progress Review Codes:

N = New

C = Continue

A = Achieved

R= Revised

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

D = Discontinued

Transition Planning
Date of IFSP:

Initial

Annual

Addendum / Date:

Date Child Turns 3:

This page describes transition activities that you and your family can expect over the next year. Transitions are big changes that
occur in your early intervention services or familys life. Transitions include things like: bringing your child from the hospital to home,
changing a child care provider, going to preschool, etc. This plan can help you explore options, changes in service delivery, or
identify new skills your child may need to be most successful in a new setting.

Transition activities

Who is responsible?

Date Completed

Transition For Children Who May Be Eligible For School District Services
Notify school district of potentially eligible child

27-30
months

Target Date:

Date completed:

27-33
months

Target Date:

Date completed:

30-36
months

Target Date:

Date completed:

30-36
months

Target Date:

Date completed:

30-35
months

Target Date:

Date completed:

33-36
months

Target Date:

Date completed:

36+
months

Target Date:

Date completed:

Steps: (Who will do what?)

Schedule and hold transition planning meeting

Steps: (Who will do what?)

Complete necessary evaluations

Steps: (Who will do what?)

Attend eligibility meeting upon invitation

Steps: (Who will do what?)

Schedule family visits if appropriate

Steps: (Who will do what?)

Attend IEP meeting upon invitation

Steps: (Who will do what?)

Post Transitional Activities

Steps: (Who will do what?)

Other

School District #

Start Date:

Contact Information:

Summary of Services
Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

Date completed:

Date of IFSP:
6 Month review

Initial

Annual

Early

Person(s)/

Intervention Services

Agency(ies)
Responsible

Addendum / Date:

Method
Start Date
End Date

(Group/Individual)

Frequency
(How Often)

Intensity

Funding
Source

*NE

If Medicaid,
MID #

Y or N

(Total min/month)

Yes

Yes

Yes

Yes

Yes

Yes

Yes

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

Diagnosis Description:

Medical Code:

Educational Code:

ITP Code:

Consent by Parents/Guardians for Provision of Services

I participated in the development of this plan. I understand that with receipts of my Procedural Safeguards, this plan
serves as Prior Written Notice for evaluation, placement, and/or the provision of listed services. 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 Signature and Financial Authorization

I have reviewed the above health-related services and certify that they are medically necessary.
*Physician Signature: __________________________________________________ Date: _________________
(*Required for Medicaid Reimbursement)

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: __________________

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed:

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
Services

Setting

Outcome #

(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 Services(s) and/or Support(s) into Natural Environments:

Projected Review Date:

Date of Review:
Participants (including Parents/Caregiver):

Recommendations:

Idaho Infant Toddler Program

Childs Name:

Individualized Family Service Plan Field Test 9/09

Date Completed: