Individualized Family Support Plan (IFSP)

Your Family’s Information
Child’s Information
Child’s Name:
Last	First	MI	AKA
DOB:	Child ID #:	Gender:
Caregiver(s)
Caregiver Type:
Caregiver Name(s):
Address:
City:	Zip Code:	County:
Cell Phone:	Home Phone:	Work Phone:	Ext:
Best time to call:	Email:
Caregiver Type:
Caregiver Name(s):
Address:
City:	Zip Code:	County:
Cell Phone:	Home Phone:	Work Phone:	Ext:
Best time to call:	Email:
Language
Child’s Primary Language/Mode of Communication:
Primary Language Used in Home/Mode of Communication:
Is an Interpreter needed for the family?
IFSP Information
Referral Date:	IFSP Periodic Due Date:
Initial IFSP Due Date:	Actual Periodic Date:
Actual Initial Date:	Annual Due Date:
Current IFSP Date:	Actual Annual Date:
IFSP Type:	Date Child turning 3:
Transition Due Between:	&
Contact Information
Agency:
Service Coordinator:
Phone:	Ext:	Fax:	Email:
Address:	City:	Zip:
Family Resource Specialist:
Phone:	Ext:	Fax:	Email:
Address:	City:	Zip:

Getting to Know Your Child and Family
Young children learn best through routines and activities that they are interested in and participate in often. It is helpful for us to know where and how your child regularly spends time so that we can develop this plan. As you and your Service Coordinator talk about your daily routines, she/he will summarize that information below.
What brought you to Early Steps?
Family: Who lives in your household?
Name:	Relationship:
Self (Child)

Routine/Participants: Your child is able to complete the following routines:
Routines	Location	Caregivers Involved	Times	Ability to Accomplish	What do you and your child enjoy about this activity? What makes this routine/activity challenging or difficult?
Morning Activities
Getting up in the morning
Dressing
Toileting
Nap Time
Inside Play
Other:
Other:
Daytime Activities
Traveling in the car
Childcare
Going from one activity to another
Outside play
Going out to eat
Community Activities
Religious services
Attending medical appointments/ Doctor visits
Grocery Shopping
Other:
Other:
Evening Activities
Meal Time
Bath Time
Family Games
Going to Bed
Other:
Other:
Successes: What success would you like to share about your child’s development? What are your favorite family experiences with your child?
Concerns: What are your most important concerns about your child’s development? What difficulties does your family/child experience during your daily routine?
Priorities: What are your priorities? What would you like Early Steps to focus on?
Additional Information: Is there anything else you would like to share?

Health Status & Insurance
Date information gathered:	Chronological age:	months
Primary Pediatrician	Other Physician(s)	Physician Type	Phone
Office Name
Address
City	State	Zip
FL
Phone	Fax
Primary Insurance	Member ID	Group/MED Type	Policy Holder	DOB
Secondary Insurance
Bill Private Insurance:
Tell us about your child’s health:
Was your child born full term?	Date of child’s last well check:
How many weeks?	Birth Weight:	0	0	oz. or	0	g	Are immunizations current?
Is your child currently on medication?	Does your child have any medical conditions and/or diagnosis?
If so, what types and why? Please List:	If yes, please describe:
Has your child been hospitalized?	Describe any family medical history that may be important for the
Please describe when & why:	team to know:
Does your child have allergies?	Please share information about any medical/therapy evaluations
Describe:	your child has received:
Your child’s nutritional habits/preferences. Describe:	Your child’s sleep patterns (bedtime, naps, hours of sleep) Describe:
Hearing	Vision
When was your child’s most recent hearing screening?	When was your child’s most recent vision screening?
What were the results?	What were the results?
Do you have concerns about your child’s hearing?	Do you have concerns about your child’s vision?
Describe:	Describe:
Developmental Screening: Was a developmental screening conducted today?

Please list the tools/methods used:
As a result of the screening, there are possible delays in the following areas of development:
Adaptive	Social-Emotional	Communication	Motor	Cognitive	None
Person completing screening (Print Name):
Next Steps:

Your Child’s Service Coordination/Targeted Case Management Plan
Your Service Coordinator’s name is . He/she can be reached by phone at and by email at . The family Resource Specialist, , is also available to provide parent support. He/she can be reached at or by email at .
Targeted Case Management Review Date(s):
Below are medical or additional supports your child and family receive or would like help receiving that are not required or covered by Early Steps:
Medical or additional supports your child or family receives or would like assistance with:
Child Care/Enrichment	Currently Receiving	Would Like Help Receiving	NA
Before/After Childcare	☐	☐	☐
Camps	☐	☐	☐
Child Care/Enrichment	☐	☐	☐
Early Head Start/Head Start	☐	☐	☐
Parenting Classes	☐	☐	☐
Income Assistance
Emergency Financial Support	☐	☐	☐
Food Stamps/SNAP	☐	☐	☐
Low Income Housing	☐	☐	☐
Public Assistance/TANF	☐	☐	☐
SSI/SSDI	☐	☐	☐
Transportation	☐	☐	☐
WIC	☐	☐	☐
Medical/Health
Counseling Assistance	☐	☐	☐
Dental Services	☐	☐	☐
Home Health Care	☐	☐	☐
Immunizations	☐	☐	☐
Medical Insurance	☐	☐	☐
Mental Health Care	☐	☐	☐
Substance Abuse	☐	☐	☐
Nutrition Classes	☐	☐	☐
Prenatal Care	☐	☐	☐
Primary Health Care	☐	☐	☐
Other
Accessibility	☐	☐	☐
Adult Education	☐	☐	☐
Equipment	☐	☐	☐
Recreation Programs	☐	☐	☐
Safety	☐	☐	☐
Support Groups	☐	☐	☐
Other:	☐	☐	☐
Other:	☐	☐	☐
Additional Notes:
Your Child’s Service Coordinator/Targeted Case Management Goals:

Person Responsible for Providing Assistance or Support	Date of Referral/Activity	Agency/Individual to Whom Child/Family is Referred	Referrals/Activities to be Completed by Service Coordinator

Your Child’s Assessment/Eligibility Determination Part I
For children to be active and successful participants at home and in the community, they need to develop skills in the three functional areas described below. We use this information about your child’s abilities and your concerns and priorities to understand your child’s progress.
Date of evaluation/assessment:	Chronological Age:	Months
Instruments/Sources Used:
Functional Areas	Activities Your Child Does Well What are some things your child likes to do? What skills does your child demonstrate or is beginning to demonstrate?	Activities Your Child Finds Difficult What are skills that your child does not do or skills that are difficult for your child? In what activities or skill areas does your child need support and/or practice?	Your Child’s developmental levels based on the evaluation and assessment:
DEVELOPLING POSITIVE SOCIAL-EMOTIONAL SKILLS	This includes your child’s ability to engage others including developing relationships, self-soothing strategies for becoming and remaining calm, getting along with others, and expressing feelings.	Social/Emotional:
Score
☐	Indicates an area of delay as defined by Early Steps
Periodic Review
ACQUIRING AND USING KNOWLEDGE AND SKILLS	This refers to your child’s ability in areas such as thinking, reasoning, remembering, problem solving, number concepts, and counting. It also includes skills related to language and literacy.	Communication:
Score
☐	Indicates an area of delay as defined by Early Steps
Cognitive:
Score
☐	Indicates an area of delay as defined by Early Steps
Periodic Review
USING APPROPRIATE ACTIONS TO MEET NEEDS	This includes your child’s ability to take care of basic needs such as getting from one place to another, dressing, feeding, toileting, and using tools (forks, toothbrushes, crayons).	Gross Fine Motor:
Score
☐	Indicates an area of delay as defined by Early Steps
Self Help:
Score
☐	Indicates an area of delay as defined by Early Steps
Periodic Review
Additional Information Regarding Eligibility/Assessment:

Your Child’s Assessment/Eligibility Determination Part II
Vision and Hearing Status:
Observations/Comments:
Eligibility:
Additional information regarding eligibility:
Assessor:	Discipline:	Signature:	Date:
Assessor:	Discipline:	Signature:	Date:
Assessor:	Discipline:	Signature:	Date:
Assessor:	Discipline:	Signature:	Date:
Assessor:	Discipline:	Signature:	Date:
*Indicates the appropriate license professional member(s) of the IFSP team providing support and direction, if applicable.

Outcomes
Outcomes are the benefits for your child and family as a result of Early Steps services and supports based on your priorities. The team will develop strategies and timelines to determine progress towards achieving the outcomes.
Outcome #
Given what you’ve shared about your family’s daily life, what would you like to see happen in your daily routines as a result of Early Steps services?
This outcome is related to the following functional area(s):
Please describe how progress will look in three months:
Please describe how progress will look in six months:
Strategies: Below are the steps to accomplish this outcome and the role of each team member:
Action Steps	Team Members
IFSP Review:	Review Date(s):
We did it!	We’re making progress	Let’s make adjustment	No longer needed	Postponed
Progress: Please describe progress toward meeting this outcome.
Please describe the next steps:

Services Needed to Achieve Early Intervention Outcomes
The below services are recommended by your team to support your family in meeting the developmental needs of your child. You have the right to accept or decline some or all the recommended services.
Service Description	Outcome #	Frequency	Intensity (Minutes)	Provider Name & Phone	Primary Service Provider	Location	Auth. Start Date	Auth. End Date	Date Services Must Start by	Payer

Non-Natural Environment Justification
Services must be provided in day-to-day routines, activities, and places that promote learning opportunities for your child and family. This means settings, including home and community settings, that are natural or typical for your child’s age peers (natural environment). As a team, we decided outcomes cannot be met in a natural environment due to the following individualized reasons:
Diagnosis Codes:
ICD-10 Codes	ICD-10 Description
Medical Necessity: If your child is a Medicaid recipient, the services reimbursed by Medicaid must be medically necessary. The following is an explanation of the medical necessity of your child’s services, if applicable:
Complete below if using as the Plan of Care for Therapy Services:
The services above are medically necessary:	Date:
(Signature)
Title:
(Primary Care Provider, ARNP, Physician’s Assistant, or a designated physician specialist)
Plan Approval
☐	I participated fully in the development of this plan.
☐	A copy of my procedural safeguards (Summary of Family Rights) has been explained and provided to me.
☐	I give consent for all of the services described in this Individualized Family Support Plan (IFSP) to be provided as written.
☐	I do not provide consent for the following services recommended by my IFSP team:
Parent/Guardian Signature:	Date:
Parent/Guardian Signature:	Date:
Consent for Services for Children in Custody of Department of Children and Families (DCF) Under Chapter 39, F.S.
I give consent for medical care and treatment per Section 743.0645, Florida Statutes, and as modified in this IFSP
DCF Caseworker/Designee Signature:	Date:

Transition
The Transition plan outlines the steps and services to support your child and family as you leave Early Steps.
Preparing for Your Transition Conference
The following are options your family is interested in after your child turns three:
☐	Local school district (Pre-K)
☐	Head Start
☐	Agency for Persons with Disabilities
☐	Early care and education programs
☐	Other:
☐	The Understanding Notification Brochure was provided.	Date:
Notification was provided to the local school district.	Date:
Notification was provided to the Department of Education.	Date:
Additional information regarding Notification, if applicable:
Your Transition Conference
Transition Conference Date:
What are your most important questions or concerns regarding your child’s transition from Early Steps?
The following activities will occur to address your questions and concerns:
The below agency/programs provided information regarding their services that included the evaluation/eligibility process:

The following activities will support your child’s transition into a new setting/environment:
Family will:	Timeline	Agency/Program will:	Timeline	Service Coordinator will:	Timeline

We attended the transition conference and participated in the development of this transition plan.
Parent/Guardian	Parent/Guardian
Service Coordinator	Local School District Representative
Program/Agency Representative	Program/Agency Representative
Other	Other