Sample Individualized Family

Service Plan
I. Child and Family Information
Child’s Name Maria Ramirez Date of Birth 12-9-14      Age in Months 30    Gender F

Parent(s)/Guardian(s) Bruce & Catherine Ramirez Address 2120 Valley Park Place     Middletown,      IN 46610

Street City Zip Code

Home Telephone No. (513) 555-0330 Work Telephone No. (513) 555-1819

Preferred Language English Translator Appropriate     Yes X No

II. Service Coordination

Coordinator’s Name    Susan Green    Agency   Indiana Early Intervention Program            

Address 105 Data Drive     Burlington,     IN 46980 Telephone No. (513) 555-0214           

Street City Zip Code

Appointment Date 6-16-17

III. IFSP Team Members

Name Agency Telephone No. Title/Function
Susan Green Indiana Early Prevention (El) Program 513-555-0214 Service Coordinator

Mr. and Mrs. B. Ramirez N/A 513-555-0330 Parents

Barbara Smith Indiana El Program 513-555-0215 Speech/Language Pathologist

Martha Kind Indiana El Program 513-555-0213 Occupational Therapist

Libby Young Middletown Preschool Program 513-555-3533 Preschool Teacher

IV. Review Dates

Date of IFSP   6-16-17   Six-Month Review   12-15-17   Annual Evaluation Not applicable

V. Statements of Family Strengths and Resources

Maria’s parents are well-educated professional individuals with realistic goals for her educational development. The entire family unit,
including her grandparents, are committed and motivated to assist her in any way. Because of the family’s geographic location, limited
resources are available for service delivery at this time.
VI. Statements of Family Concerns and Priorities
Concerns
Due to Maria’s medical diagnosis of Down syndrome, her parents are concerned about appropriate early intervention services to assist in
ameliorating her developmental delays. Additionally, the parents have stated a reluctance about a change in Maria’s service delivery from
her natural environment (i.e., her home) to an inclusive community-based preschool.

Priorities
The priorities that Maria’s parents have for her include improving her communication skills, her ability to use utensils, and her toileting
skills. They desire services to be delivered at home with the eventual goal of a placement with typical children who attend the local kinder-
garten. Her parents and grandparents want to learn ways in which they can help to facilitate Maria’s development in her natural environment.

VII. Child’s Present Level of Development and Abilities

Cognitive Skills (Thinking, reasoning, and learning)
Maria’s cognitive abilities are commensurate with a 20-month-old child. She’s extremely inquisitive and understands simple object concept
skills. Imitative play is consistently observed; however, discrimination of objects, persons, and concepts continues to be an area of need.

Communication Skills (Understanding,

communicating with others, and expressing self with others)
Communication/language competency skills appear to be similar to that of an 16-month-old toddler. Her receptive language is further
developed than her expressive abilities. Primitive gestures are her primary mode of communication. She consistently exhibits a desire/
interest to interact with others. Verbal responses primarily consist of vocalizations and approximations of single word utterances
(e.g., ma-ma, da-da, ba-ba),

Self Care/Adaptive Skills (Bathing, feeding, dressing, and toileting)

Feeding, in general, such as drinking from a cup and finger feeding, is appropriate at this time. A great deal of assistance from caregivers
is still required for daily dressing tasks and toileting.

Gross and Fine Motor Skills (Moving)

Maria appears to be quite mobile. She is adept at rambling and walking, but needs to improve muscle strength and endurance. She enjoys
movement to music. She can scribble, grasp large objects, turn pages of books, and prefers using her right hand while performing tasks.
She needs to work on her ability to use utensils and writing tools.

Social-Emotional Development
(Feelings, coping, and getting along with others)
Maria is a very happy, affectionate, and sociable child. She enjoys being the center of attention and engaging in interactive games; how-
ever, she appears content to play alone. Temper tantrums are triggered by frustration from her inability to communicate. Sharing and
turn taking continue to be difficult for Maria,

Health/Physical Development (Hearing, vision, and health)

Maria’s general health is good, but she has a history of chronic otitis media and upper respiratory infections. Vision and hearing are
monitored frequently.
VIII. Outcome Statements
1. Participate in stimulation of all language modalities (visual, auditory, tactile) in order to increase communication competency.

Responsible Begin End Frequency Evaluation

Strategies/Activities Person/Agency Date Date of Service Location Criteria
1.1 Maria will use word approximations SLP 6-19-17 12-15-17 Once Home Preschool
combined with consistent gestures weekly Language Scale
for 5 different needs across 3
different people and 2 different
settings.
1.2 Maria will use words combined with Mom and Dad 6-19-17 12-15-17 Observation
signs for 5 different needs across samples
3 different people and 2 settings.

2. Maria’s daily self-care skills will improve in the areas of dressing and toileting abilities.

Responsible Begin End Frequency Evaluation

Strategies/Activities Person/Agency Date Date of Service Location Criteria
2.1 Maria will push down/pull up under- Mom and Dad 6-19-17 12-15-17 Once weekly Home Observations
garments with minimal assistance. Service Coord.
2.2 Maria will establish a consistent Mom and Dad 6-19-17 12-15-17 Once weekly Home Recorded data
pattern of elimination. Service Coord. of frequency of
elimination
2.3 Maria will spontaneously indicate Mom and Dad 6-19-17 12-15-17 Once weekly Home Observation
by gesture and vocalization the Service Coord. samples
need for going to the restroom.

3. Maria will develop improved abilities to discriminate auditorv/visual stimuli.

Responsible Begin End Frequency Evaluation

Strategies/Activities Person/Agency Date Date of Service Location Criteria
3.1 Indicate by pointing/verbalizing Mom and Dad 6-19-17 12-15-17 Once weekly Home Observations
whether objects are the same or Service Coord.
different.
3.2 Sort several colors and shapes Mom and Dad 6-19-17 12-15-17 Once weekly Home Observation
consistently. Service Coord. samples
3.3 Imitate words and motions in Mom and Dad 6-19-17 12-15-17 Once weekly Home Observation
songs upon being given a model. Service Coord. samples

IX. Transition Plans

If eligible, the following steps will be followed to transition Maria Ramirez to Part B services on or about
child’s name
      1-3-18      

projected transition date

1. The service coordinator will schedule meeting with parents to explain the transition process and rationale, review legal rights,
and ascertain their preferences and need for support.
2. The service coordinator will arrange for Maria and her parents (and grandparents) to visit the center and meet teachers, staff, and
children.
3. The service coordinator will arrange for Maria to visit her classroom on at least three occasions in the month prior to her transition date.
4. At least 90 days prior to Maria’s third birthday, the service coordinator will convene a meeting to further develop Maria’s
transition plan.
X. Identification of Natural Environments
The home environment is considered to be Maria’s natural environment at this time.

Justification for not providing services in natural environment:   Not applicable.  

XI. Family Authorization

We (I) the parent(s)/guardian(s) of Maria Ramirez hereby certify that we (I) have had the opportunity to participate in the
development of our (my) son’s/daughter’s IFSP. This document accurately reflects our (my) concerns and priorities for our
(my) child and family.

We (I) therefore give our (my) permission for this plan to be implemented. X       
Yes No

  Catherine Ramirez      6-16-17     Bruce Ramirez         6-16-17

signature of parent/guardian date signature of parent/guardian date

SOURCE: Adapted from R. Gargiulo and J. Kilgo, An Introduction to Young Children with Special Needs (4th ed.) (Belmont, CA: Wadsworth/Cengage Learning, 2014),
pp. 327-330.