Healthcare IFSP Review

HEALTHCARE IFSP REVIEW

Child Name:    Date of Birth:

Medical Record/ID:    IFSP Review Date:

Primary Contact and Family Information

Phone:    Email:

Participants in Review

The persons listed below participated in or were invited to the IFSP review meeting (check present):

Parent/Caregiver present     Service Coordinator present

Physical Therapist     Occupational Therapist     Speech-Language Pathologist

Regional Specialist/Other    If other, specify:

Current IFSP Goals and Progress

Summarize each active IFSP goal and indicate progress made since the last review. Include measurable criteria and current performance levels.

Assessments, Observations, and Clinical Findings

Document formal and informal assessments, observational findings, standardized scores (if applicable), and clinical impressions that inform service decisions.

Service Summary and Recommendations

For each recommended service, indicate frequency, duration, start date and provider. If continuing without change, indicate "continue".

Service: Physical Therapy — Frequency/Duration:    Start Date:    Provider:

Service: Occupational Therapy — Frequency/Duration:    Start Date:    Provider:

Service: Speech-Language Therapy — Frequency/Duration:    Start Date:    Provider:

Service: Special Instruction / Developmental Intervention — Frequency/Duration:    Start Date:    Provider:

Recommended Changes to the IFSP

Indicate whether the review resulted in changes to goals, services, or placement.

Add service(s)    Modify service(s)    Continue without change    Discontinue service(s)

Parental Consent and Rights

By signing this IFSP review, the parent/guardian attests that they have participated in the review meeting, have been provided with the opportunity to ask questions, and understand the recommended services and changes. The parent/guardian retains the right to accept, decline, or request modifications to proposed services and to withdraw consent at any time.

I consent to the recommended changes described above.

I decline the recommended changes at this time and request continuation of prior IFSP provisions.

I request additional information or evaluation prior to making a decision.

Confidentiality / Privacy Acknowledgment

Records related to the IFSP and this review are protected and maintained in accordance with applicable confidentiality requirements. Information will be shared only with authorized persons involved in the child's care, unless otherwise authorized in writing by the parent/guardian.

I acknowledge receipt of privacy and confidentiality information and understand how my child's information will be used and disclosed.

Service Coordinator / Agency Information

Phone:    Email:

Authorization Expiration

Unless otherwise noted, the IFSP review decisions documented herein remain in effect until the next formal review or until the date below.

Effective Through (Expiration Date):

Additional Notes / Parent Concerns

Sign Now