Individualized Family Service Plan Template

INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP) TEMPLATE

Child and Family Information

Child Name:   Date of Birth:   Student ID:

Primary Language:   Phone:   Email:

Eligibility and Evaluation Summary

Eligibility Determination Date:   Eligibility Category: Developmental delay Established medical condition At risk for delay

Present Levels of Development

Family Priorities, Concerns, and Resources

Outcomes / Measurable Results

Describe specific, measurable, family-centered outcomes that will be achieved for the child and family. Include criteria and target dates.

Criteria/Expected Level:   Target Date:

Criteria/Expected Level:   Target Date:

Early Intervention Services

List all services necessary to achieve the outcomes. For each service indicate provider, frequency, location, and projected dates.

Therapy (PT/OT/ST) Special Instruction Family Training/Support

Frequency:   Location/Natural Environment:

Projected Start Date:   Projected End Date:

Natural Environments and Access

Services will be provided in natural environments to the maximum extent appropriate, including the home and community settings in which children without disabilities participate. The team affirms that services are to be delivered in settings that promote development through family routines and activities unless documented justification for a different setting is provided.

Transition Planning (to Preschool/Other Services)

Transition meeting scheduled on:   Agency Responsible for Transition Referral:

Parent/Guardian consent to referral for transition activities: Yes No

Consent and Authorizations

By signing below, the parent(s)/legal guardian(s) and the primary service coordinator certify that the IFSP was developed in a timely manner, that the content of the plan was explained and discussed, that informed consent has been obtained for services and for release of information where applicable, and that the family has been provided with a copy of this IFSP. The family retains the right to withdraw consent at any time in accordance with applicable procedures.

Consent to exchange information for coordination of services: Yes No

Consent to bill private insurance or public benefits where applicable: Yes No

Plan Review and Revisions

Initial Plan Date:   Next Scheduled Review Date:

Procedure for amendment: The IFSP may be amended at any time by agreement of the parent(s)/guardian(s) and program representatives. Significant changes in services or outcomes will be documented in writing and provided to the family.

Primary Service Coordinator

Phone:   Email:

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