Individualized Family Service Plan

Child's information:
Name: ______________________________________________________________ Early Intervention #: _____________________ Date of birth: ____/____/________
Address: _____________________________________________________________________________________ Age (in months) ______ Gender: ______
Phone: (_____)____________ Language child hears most of the day/mode of communication: __________________________________________________________
Primary parent or guardian:
Name: ______________________________________________________________ Relationship to child: _____________________ Interpreter Required Yes No
Address: _____________________________________________________________________________________ Phone: (_____)____________
Preferred Language / Mode of Communication: _____________________________________________________________________________________
Other parent or guardian:
Name: ______________________________________________________________ Relationship to child: _____________________ Interpreter Required Yes No
Address: _____________________________________________________________________________________ Phone: (_____)____________
Preferred Language / Mode of Communication: _____________________________________________________________________________________
Conference information:

Initial Interim Six month Transition conference Amendment

Date of conference: ____/____/________

Participants:
________________________________________ Parent or legal guardian

________________________________________ Other parent or legal guardian

________________________________________ Initial service coordinator

________________________________________ Ongoing service coordinator

________________________________________ _____________________
Other participant
Role

________________________________________ _____________________
Other participant
Role

________________________________________ _____________________
Other participant
Role

________________________________________ _____________________
Other participant
Role

Page 1

Child's name: ____________________________

EI#:__________________

DOB: ____/____/________

Conference date: ____/____/________

Age: ______

Family priorities, concerns and resources:

Family concerns about child:
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Family resources:
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What are your childs and family's daily activities? Where does your child spend the day? With whom does your child regularly interact? What are your childs activities,
routines and favorite toys?
_______________________________________________________________________________________________________________________________________
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Which of your child's daily routines and activities would you like early intervention to help you with?
_______________________________________________________________________________________________________________________________________
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Child's name: ____________________________

EI#:__________________

DOB: ____/____/________

Conference date: ____/____/________

Age: ______

Present Levels of Development

Communication: How your child understands and lets you know what he or she wants or needs.

Test/evaluation:

_______________________________________________________________________________________________________________________________________
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Social/Emotional: How your child gets along with family members and other people.

Test/evaluation:

_______________________________________________________________________________________________________________________________________
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Cognitive: How your child understands concepts and solves problems.

Test/evaluation:

_______________________________________________________________________________________________________________________________________
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Adaptive: How your child performs tasks such as eating, dressing, bathing, toileting and sleeping.

Test/evaluation:

_______________________________________________________________________________________________________________________________________
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Motor: How your child moves and uses his / her hands.

Test/evaluation:

_______________________________________________________________________________________________________________________________________
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Child's name: ____________________________

EI#:__________________

DOB: ____/____/________

Conference date: ____/____/________

Age: ______

Outcome
Outcome:
Short term goals that should be achieved in order for the child to reach the outcome:

Methods of measurement:
Progress:
Reasons for not achieving outcome:
Outcome:
Short term goals that should be achieved in order for the child to reach the outcome:

Methods of measurement:
Progress:
Reasons for not achieving outcome:
Outcome:
Short term goals that should be achieved in order for the child to reach the outcome:

Methods of measurement:
Progress:
Reasons for not achieving outcome:
Outcome:
Short term goals that should be achieved in order for the child to reach the outcome:

Methods of measurement:
Progress:
Reasons for not achieving outcome:
Outcome:
Short term goals that should be achieved in order for the child to reach the outcome:

Methods of measurement:
Progress:
Reasons for not achieving outcome:
Outcome:
Short term goals that should be achieved in order for the child to reach the outcome:

Methods of measurement:
Progress:
Reasons for not achieving outcome:
METHODS OF MEASUREMENT
1. Professional/ EI observation
2. Parent report
3. Assessment

4. Check lists
5. _________________
6. _________________

PROGRESS
1. Not applicable at this time 4. Progress made; outcome not achieved
2. No progress made
5. Outcome achieved
3. Little progress made

REASONS FOR NOT ACHIEVING OUTCOME

1. More time needed
4. _________________
2. Illness
5. _________________
3. _________________ 6. _________________

Page 4

Child's name: ____________________________

EI#:__________________

DOB: ____/____/________

Conference date: ____/____/________

Age: ______

Services and assistive technology

Service

Provided by: (Discipline)

Type*

Location

Language

Frequency

Minimum
number of
sessions:

Time

* Indicate type of service Individual Group Consultation Monitor

If any services are not being provided in the child's natural environment, explain why the IFSP team thinks this is appropriate:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
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If any services provided in group settings without typically developing peers, explain why the IFSP team thinks this is appropriate:
_______________________________________________________________________________________________________________________________________
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If assistive technology device(s) are required, describe assistive technology device:
_______________________________________________________________________________________________________________________________________
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