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Office of the State Superintendent of Education

Division of Specialized Education

Strong Start

INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP)

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Table of Contents


Child and Family Information

Dedicated Service Coordinator Information

Projected IFSP Meeting Dates

Team Participant Signatures

PART I – INFORMATION ABOUT MY CHILD’S DEVELOPMENT

Section A – Health Information

Section B – Present Levels of Development

Section C – Eligibility for Early Intervention Service

Section D – Strengths and Needs

PART II – INFORMATION ABOUT MY Family

Section A – Concerns, Priorities, and Resources

Section B – Routines in Natural Environments

PART III – MY Child/Family Outcomes Related to My Child’s Development

PART IV – My Child’s Early Intervention Services

PART V – Service Linkages

PART VI – Authorization(s)

PART VII – My Child’s Transition Information

TRANSITION PLAN

TRANSITION Conference

TRANSITION Conference – Signature Page

Revised 07/13

Office of the State Superintendent of Education • Division of Special Education

Strong Start


Referral Date: 1/18/2017 IFSP Meeting Date: 2/22/2017 IFSP Meeting Type: ☐ Interim ☒ Initial ☐ Annual

Child and Family Information

Child Name (First/Middle/Last):

2/11/2013 Quinn Riddell

Birth Date: 6/1/2016 ID Number: 11684 Health Plan and No: BCBS

Address: 4501 Connecticut Ave. Apt. 1114 WDC 20008 Home Phone: Click here to enter text.

Parent/Guardian/Surrogate Name(s) (First/Middle/Last): Ashley & Quinn Riddell

Address: Same as listed above Work Phone: Click here to enter text.

Other Address: Click here to enter text. Cell Phone: 443-928-3780-mom

E-mail: [email protected]; [email protected] Cell Phone: 301-525-1219-dad

Best Time to Contact: Anytime Best Method of Contact: ☐ Home Phone ☐ Work Phone ☒ Cell Phone ☒ E-mail

Dedicated Service Coordinator Information

If you have questions about this IFSP or any of the individuals working with your child and family, contact your service coordinator.

Service Coordinator Name: Kyera Hooks, MS

Agency: Connections Therapy Center

Address: 3849 Alabama Ave, SE Washington, DC 20020

Work Phone 301-887-7911 E-mail: [email protected]

Projected IFSP Meeting Dates

Projected Date Six Month IFSP Review: 8/22/17

Projected Date Annual IFSP Meeting: 2/22/18

Projected Date Transition Planning Meeting: 6/1/18

mailto:[email protected]

Name Quinn Riddell ID 11684 Date 2/22/2017

Revised 07/13


Revised 07/13


Section A – Health Information

What was your child’s gestational age at birth? 40 Weeks Click here to enter text.

Days

What was your child’s birth weight? 6 Pounds 12 Ounces OR Click here to enter text.

Grams

Who is your primary care physician or other health care professional? Dr. Hall

Phone: (301) 832 - 6048

IMMUNIZATIONS

Do you have a copy of your child’s immunization record? ☒ Yes ☐ No

If NO, please indicate the strategies to be used to obtain a copy of your child’s immunization record:

Click here to enter text.

LEAD SCREENING/TESTING

Has your child’s lead level been tested? ☐ Yes ☒ No If YES, what was the level?

Are there any concerns about your child’s lead level? ☐ Yes ☒ No If YES, please explain:

Click here to enter text.

NUTRITION

Are there any concerns about your child’s eating, general nutrition or growth? ☐ Yes ☒ No If YES, please explain:

Family reports Quinn is a great eater.

GENERAL HEALTH CONCERNS

Is there anything about your child’s health (special equipment, allergies, other mental or physical information) that the team should know about to better plan and provide services to your child and family?

Quinn recently was discharged of wearing helmet as she fell w/in normal range -2 weeks ago. Quinn has a an upcoming 9 mth appt. and will further discuss Quinn’s Dx w/ pediatrician b/c mom feels that Quinn may have torticollis in addition Dx of Plagiocephaly.


Revised 07/13


Section B – Present Levels of Development

Evaluation Status: ☒ Entry ☐ Annual ☐ Exit

Area

Date of Assessment

(MM/DD/YYYY)

Name of Assessment Instrument(s)

Chrono-logical Age

Age Level/ Age Range Qualitative Description

Cog

nitiv

e

Cognitive

(Playing, thinking and exploring)

01/24/17 Assessment Tool: Assessment, Evaluation and Programming System for Infants and Children (AEPS), 2nd Edition. Location: Family’s home

7 Mths AEPS Cognitive Results: Falls at the cutoff of the range for typically developing children

The cognitive domain measures the ability to learn new skills, understand new concepts, make sense of current events, solve problems and use memory. Quinn was seen in her home with her mother and father present. She quickly warmed up to the evaluators, watching them as they moved around the room. Quinn is very interested in the world around her and will follow people with her eyes as they move into and out of her field of vision. She likes to examine different toys by looking, patting, and mouthing them. If a toy is out of reach she will often do whatever she can to get to it. This may include rolling toward it or, if it is on a blanket, pulling the blanket closer to her to bring the toy closer to her. Quinn enjoys interactive games such as “Peekaboo” and will respond by smiling or laughing. Quinn can intentionally hold one item at a time and is learning how to hold two items, one in each hand. Additionally, Quinn is learning to enjoy reading and will at times look at the pictures, but other times does not show interest. Quinn’s cognitive development falls at the cutoff of the range for typically developing children, indicating development may be delayed.

C

om

mun

ica

tio

n

Communication

(Understanding others and expressing one’s self)


7 Mths AEPS Social-Communication Results: Falls within the range for typically developing children.

Receptive communication refers to a child’s ability to discriminate, recognize, and understand sounds, words, and gestures of others. Quinn was alert and attentive during the evaluation. She turned her head toward her parents as they spoke. She was able to track an object with her eyes and establish joint attention. Quinn gazed and smiled at evaluators when she was spoken to. When her mother called her name, Quinn looked up while laying on her tummy. She did not appear to look up when other names were called and mom reports that she has been trying to get her to recognize her own name. She is able to quiet to a familiar voice. Expressive language is a measure of a child’s vocabulary and word combinations that are used to verbally communicate. Quinn was very vocal during the


Revised 07/13

evaluation, actively cooing and babbling. She was able to use sounds and gestures to respond to simple questions of one evaluator. She will vocalize to express various affective states and uses gestures and actions to reject unwanted items or people. Quinn is developing the ability to use jargon and will often shriek. Overall, Quinn’s communication development is average when compared to age-matched peers.

So

cia

l o

r

Em

otio

na

l

Social or Emotional

(Emotions, feelings, and interacting with others)


7 Mths AEPS Social: Results: Falls within the range for typically developing children.

Social or Emotional Development refers to a child’s ability to engage in meaningful social interactions with adults and peers. Quinn was very happy and calm during the evaluation. She enjoys social games such as peekaboo and responds appropriately to familiar adult affective tones. Quinn is described to be very affectionate and will display her affection through hugs. She is developing the ability to initiate communicative exchanges with adults, but responds well to social routines. Quinn is inquisitive when playing near peers and will observe them closely. She is able to entertain herself by playing appropriately and independently with her toys. Quinn is learning how to wave and will wave her hand inward, toward herself. Overall, Quinn’s social/emotional development is average when compared to age-matched peers.

Ad

ap

tive

Adaptive

(Eating, drinking, toileting, and doing things for one’s self)


7 Mths AEPS Adaptive: Results: Falls within the range for typically developing children.

Adaptive development refers to a child’s ability to use what they know about the world and their environment for skills in daily life. Quinn is breast-fed 3-4 times a day but will eat solids 2-3 times a day. She will clear the contents of the spoon presented to her without problems and chews and swallows without any problems. She can eat all textures including fruits and vegetables and mostly feeds herself using her fingers. Quinn is drinking from a sippy cup, but is not yet drinking water as she will spit it back out. Quinn is sleeping through the night. Overall, Quinn’s adaptive development is average when compared to age matched peers.

Ph

ysic

al

Fine Motor

(Using hands for play, feeding or other activity)


7 Mths AEPS

Fine Motor: Results: Falls below the range for typically developing children

Physical development provides children with the abilities they need to explore and interact with the world around them. A young child's physical growth first begins as muscles gain strength and they gradually develop coordination. Information for this domain was gathered through observation, family report, direct assessment. The Fine Motor domain looks at how well your child can use his or her hands and fingers to make things happen. Quinn is able to reach for and hold objects with


Revised 07/13

either hand. She is learning to bring both hands together in the middle and typically does so when she decides to bang cups together. She can also move objects from one hand to the other. Quinn is able to hold palmsized object in each hand and is learning to wrap her fingers around them. Additionally, she is learning how to pick up pea-sized items, such as food, with her fingers and at this time typically uses her fingers to rake the item toward her palm. While playing, Quinn will attempt to turn objects on utilizing one hand. Additionally, during reading time, Quinn is learning how to turn pages of books. Quinn’s fine motor development falls at or below the range for typically developing children, indicating development is delayed.

Gross Motor

(Body movement to change position or location)


7 Mths AEPS Gross Motor: Results: Falls at the cutoff of the range for typically developing children

Physical development provides children with the abilities they need to explore and interact with the world around them. A young child's physical growth first begins as muscles gain strength and they gradually develop coordination. Information for this domain was gathered through observation, family report, direct assessment. The Gross Motor domain looks at how well your child can move her body. Quinn is able to move both arms freely and can move both legs, though they frequently move together rather than independently. She easily turns her head to the right and is learning to turn her head to the left, though this is not as consistent. Quinn can sit independently while playing and has a strong neck, though her head is typically not centered and is tilted to one side. She can, however, turn her head to the left if she is interested in something happening on that side of her body, such as a new noise or if there is a person of interest to the left. Quinn is very skilled at rolling from her front to her back and her back to her front and uses this is one of her primary methods of moving around her environment. She is also about “butt scoot” to get around. Quinn can hold up the weight of her upper body with her arms while playing on her stomach and is learning how to get into a hands and knees crawling position by herself. While in the crawling position Quinn is starting to rock forward and backward in preparation of learning how to crawl. Additionally, she can use her arms to push herself backward and is learning how to roll a ball. Quinn’s gross motor development falls at the cutoff of the range for typically developing children, indicating development may be delayed.

Hearing Did your child pass a Universal Newborn Hearing Screening? ☒ Yes ☐ No ☐ Not Applicable

Has your child seen an audiologist for a full hearing evaluation? ☐ Yes ☒ No


Revised 07/13

Are there any concerns about your child’s hearing? ☐ Yes ☒ No

Results of Evaluation/Observation: Quinn received and passed her Newborn Hearing Screening; no concerns presently.

Vision Has your child’s vision been tested? ☒ Yes ☐ No

Are there any concerns about your child’s vision? ☐ Yes ☒ No

Results of Evaluation/Observation: Quinn received and passed her Newborn Vision Screening; no concerns presently.


Revised 07/13


Section C – Eligibility for Early Intervention Service

Your child is eligible for Strong Start services based upon the results of the evaluation process. Eligibility is based on the ONE category that is checked below.

☒ DIAGNOSED PHYSICAL OR MENTAL CONDITION WITH A HIGH PROBABILITY OF DEVELOPMENTAL DELAY

My child is eligible for Strong Start services because he/she has a diagnosed physical or mental condition that has a high probability of resulting in developmental delay.

Does the child have diagnosed vision impairment? ☐ Yes ☐ No

Does the child have diagnosed hearing impairment? ☐ Yes ☐ No

(If YES, please provide a copy of the Eye Medical Report or Audiological Evaluation)

The child has the following condition(s) listed in the DC EIP eligibility guidance:

Plagiocephaly

☐ AT LEAST A 50% DEVELOPMENTAL DELAY

My child is eligible for Strong Start services because he/she is experiencing at least a 50% delay in one or more of the following developmental areas; or

My child is eligible for Strong Start services because he/she is experiencing at least a 25% delay in two or more of the following developmental areas.

Adaptive Development ☐ 50% delay ☐ 25% delay

Cognitive Development ☐ 50% delay ☐ 25% delay

Communication Development ☐ 50% delay ☐ 25% delay

Gross Motor Development ☐ 50% delay ☐ 25% delay

Fine Motor Development ☐ 50% delay ☐ 25% delay

Social Emotional Development ☐ 50% delay ☐ 25% delay

Clinical Opinion of Atypical Development or Behavior ☐

My child is eligible for Strong Start services because he/she is experiencing at least a 50% delay.

Names of Clinicians: Click here to enter text. Click here to enter text.

Summary Statement of Clinical Opinion:


Revised 07/13


Section D – Strengths and Needs

A description of your child’s unique strengths and needs provides valuable information when planning for early intervention services that will support the development of outcomes for your child and family.

MY CHILD’S STRENGTHS MY CHILD’S NEEDS

What are some things my child likes to do?

What are some things my child does well?

What are some things that are challenging for my child?

What are some things my child does not know how to do yet?

• Sitting up

• Grasping – pincer grasp

• Very vocal

• Great sleeper

• Observant/Alert

• Sociable

• Separation anxiety with mom

• Not yet crawling – pushes herself places and rolls, will scoot

• Not a napper – will nap approx 30 mins

• Head tilting


Revised 07/13

PART II - INFORMATION ABOUT MY FAMILY Section A - Concerns, Priorities, and Resources

To best support your child and family, it is helpful to know about issues and concerns that are important to your family. Your family’s concerns, priorities, and resources will be used as the basis for developing outcomes and identifying strategies and activities to address the needs of your child and family. You may share as much or as little information as you choose.

MY FAMILY’S CONCERNS MY FAMILY’S PRIORITIES MY FAMILY’S RESOURCES

Concerns I have about my child’s health and development. Information,

resources, and supports I need or want for my child and/or family.

My hopes and dreams for my child. The most important things for my

child and/or family right now.

Resources that my child/family has for support, including people, activities,

programs/organizations.

Tilting of her head to the left and does not want to look that way as frequently.

Family reports they would kike for Quinn to be happy, healthy, to be on track with her developmental milestones, and eventually sleep through the night.

• Maternal grandparents

• Other extended family

• Friends

☒ Information gathered through a family-directed assessment using the DC EIP Family Interview Tool

☐ Family declined family-directed assessment.


Revised 07/13

PART II – INFORMATION ABOUT MY FAMILY

Section B – Routines in Natural Environments

Early intervention services are provided in natural environments. A natural environment is a location where your child and family spend time, such as in the home, childcare program, or other community setting. Natural environments are where typically developing children play and learn. The information below will help us determine the natural environment(s) in which your child and family will receive early intervention services.

Where does your child/family spend time? Check all that apply:

☒ Child’s home

☐ Child care center

☐ Religious setting

☐ Family child care

☐ Early Head Start

☐ Library

☐ Home of family member

☐ Toddler playgroup

☐ Family support center

☐ Parent’s place of employment

☐ Shelter

☐ Other: Click here to enter text.

What are some of the activities that you like to do together as a family?

Family activities: mom,, dad and Quinn will go out will go out for walks with the dog. They will also visit family in the area a lot. The family will also go out to eat for dinner around the neighborhood

Is there something you would like to do as a family, but cannot do at this time?

Family reports not at this time.

What are the daily routines of your child and family? Are some of these routines challenging? Are there other routines that your family would like to establish?

Quinn is with her mother daily, they will wake up at 8 am. Quinn is breast-fed 3 to 4 times a day. Quinn will eat her breakfast

and typically will eat solids at breakfast. They will go for a walk or depending on the weather they will play indoors and then

Quinn is breast-fed. Normally Quinn is breast-fed one hour after she has been fed her solids. She is breast-fed again between

11:30 and 12 pm and will eat solids around 1 to 2 pm. She will also have her early dinner of breast-feeding between 3 and 4

pm. Quinn will eat what the family is eating for dinner around 6pm. Bedtime is at 9 pm. She sleeps through the night every

night.

What are the barriers that keep your child and family from participating in your daily routines and activities?

Family reports none at this time.

How can the program best support your family in its desire to improve or create important routines?

Family would like strategies, support, and resources to ensure Quinn’s continued development in reaching her milestones.


Revised 07/13

PART III – MY CHILD/FAMILY OUTCOMES RELATED TO MY CHILD’S DEVELOPMENT

OUTCOME NUMBER: 1

Based upon information from your child’s present levels of development and shared reports, your child’s strengths and needs, your family’s concerns, priorities, and resources, and your daily routines, this plan outlines what we want to accomplish and the specific steps required. Please discuss your priority outcomes for your child and/or family, including specific skills and context. A separate “Child and Family Outcomes” form is completed for each outcome.

OUTCOME STRATEGIES/ACTIVITIES/

LEARNING OPPORTUNITES MEASURABLE CRITERIA

What would we like to see happen?

What steps need to be taken to help accomplish the priority outcome?

How will we know when the outcome is achieved?

Quinn’s Family would like her to gain full range of motion to the leftside of her neck and head, as well to midline to be able to maintain good neck and head control while on tummy time, during mealtime and playtime at home.

• Provide gentle massage to the left side of Quinn’s neck during bath time. When you feel the knot beneath your finger, provide gentle pressure and rub over it to help loosen it up a little bit.

• Place Quinn in a position that she has to turn her head to the left in order to look at mom or dad to encourage left rotation and increase range of motion to that side.

• Make sure to encourage Quinn to look to the left more often when on her stomach during tummy time and in supported sitting as well.

• Correct the alignment of Quinn’s neck by adjusting her body and not her head. Move her body over to the right a little when you see her tilting to the left to get her head in midline with her body. Continue to correct as she moves back to that position.

Quinn will have more mobility to the leftside of her neck and head and bring to midline when turning her head from left to right and right to left while on tummy time and during feedings

TIMELINE 6 MTHS

PARTICIPANTS – Who will be involved?

Name: Ashley & Andrew Riddell Title: Mom & Dad Phone/E-mail: 443-928-3780-mom

301-525-1219-dad

Name: TBD Title: Early Interventionist Phone/E-mail: TBD

Name: Title: Phone/E-mail:

Name: Title: Phone/E-mail:

REVIEW OF OUTCOME

Review Codes: Select the code that best applies. Code: Date: Comments:

1. Proficient – We did it!

2. In process – We’re making progress

3. Needs development – Let’s make adjustments

4. No longer needed

5. Postponed

RESPONSE TO REVIEW – (ONLY NEEDED FOR ADJUSTMENTS)

Review Codes: Select the code that best applies. Code: Date: Comments:


Revised 07/13

1. Revise outcome

2. Modify strategies/activities

3. Change service

4. Other:

Note: Supports and services must be provided to your child in settings that are natural or typical for children of the same age

(natural environments). If, as a team, we decide that we cannot achieve an outcome in a natural environment, we need to describe

how we made that decision and what we will do to move services and supports to natural environments as soon as possible.


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PART IV – MY CHILD’S EARLY INTERVENTION SERVICES

Early intervention services enhance the development of your child and the capacity of your family to meet the needs of your child. Each early intervention service supports your individual child and family outcomes. A separate “Early Intervention Services” form is completed for each service/support/setting.

TYPE OF SERVICE

SERVICE DESCRIPTION

SETTING Number of Sessions Frequency Intensity Method

Please specify: Physical Therapy

☒ 1

☐ 2

☐ 3

☐ 4

☐ 5

☐ 6

☐ Other:

☐ Only

☐ Daily

☒ Weekly

☐ Monthly

☐ Yearly

☐ Quarterly

☐ Semi-Annually

Number of minutes per session:

☐ 15

☐ 30

☐ 45

☐ 50

☒ 60

☐ 90

☐ Other:

☐ Group

☒ Individual

☒ Home (Principal residence

of child’s family or caregivers)

☐ Community-Based Setting

(Please specify)

☐ Other (Please specify)*

*Complete section “Justification for Other Settings” below

Type of Service

Community-Based Settings (Where children without disabilities

are typically found

Other Settings (Not community or home-based)

Audiology

Family Counseling/ Training

Health

Medical (diagnosis & evaluation only)

Nursing

Nutrition

Occupational Therapy

Physical Therapy

Psychological

Social Work

Special Instruction

-ABA

-O&M

-Aud/VB/OR

Speech/Language Therapy

Vision Services

Child care center (including family day care)

Regular nursery school

Early childhood center

Early Head Start

Library

Grocery store

Park/Playground

Restaurant

Community/ Recreation Center

Parent’s place of employment

Shelter

Early Intervention Center/Class for children with disabilities

Service Provider Location (e.g. Outpatient, Audiologist)

Hospital (Inpatient)

Residential facility

Justification for Other Settings

Supports and services must be provided to your child in settings that are natural or typical for children of the same age (natural environments). If, as a team, we decide that we cannot achieve an outcome in a natural environment, we need to describe how we made that decision and what we will do to move services and supports to natural environments as soon as possible.

Outcome(s) cannot be achieved by providing this service in natural environments because (please specify the outcome number):

We will work toward providing supports and services in natural environments to achieve this outcome by (describe plan and timeline):


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PART IV (CONTINUED) – MY CHILD’S EARLY INTERVENTION SERVICES

Financial Responsibility: Check all sources responsible for payment of services.

☒ Strong Start

☐ Medicaid

☐ Other (Please specify):

Provider Agency: Record the name of the agency providing the service.

TBD

Provider Name/Phone Number: Record the name and phone number of the individual(s) providing the service.

TBD

Projected Service Initiation Date:

Record the date on which the service is projected to begin MM/DD/YYYY

Projected Service Review Date:

Record the projected date on which the service will be reviewed MM/DD/YYYY.

Projected Duration: Record the time period that the service will be provided. MM/DD/YYYY.

Service Ending Date: Record the date on which the service ends. MM/DD/YYYY.

From:

To:

Assistive Technology

Does my child need assistive technology services or devices to increase, maintain, or improve his/her functional capabilities?

☐ Yes ☒ No

Types of Assistive Technology. Check all that apply:

☐ Activities of Daily Living (ADL)

☐ Adaptive Computer Hardware

☐ Adaptive Computer Software

☐ Auditory Aids

☐ Augmentative and Alternative Communication Device (AAC)

☐ Environmental Control Units (ECUs)

☐ Mobility Aids

☐ Play, Recreation, and Leisure Aids

☐ Seating and Positioning

☐ Transportation/Safety Aids

☐ Vision Aids

☐ Other:

Provider

Provider Name:

Phone: E-mail:


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PART V – SERVICE LINKAGES

Service linkages are community services and supports designed to enhance your child’s development and your family’s capacity to meet the needs of your child and family. A separate “Service Linkages” form is completed for each family member.

Service linkages are being provided for the following family member. (Check only ONE of the following).

☐ Eligible Child ☐ Sibling ☐ Family ☐ Parent/Guardian ☐ Other Relative

SERVICE LINKAGES TO BE PROVIDED (Check ALL that apply.)

Childcare/Enrichment

☐ Before/After Child Care

☐ Camps, Day/Residential

☐ Early Head Start/Head Start

☐ Family Day Care

☐ Group Child Care Centers

☐ In-home Child Care

☐ Preschool Program

☐ Tutoring

☐ Other:

Income Assistance

☐ Emergency Financial

Assistance

☐ Financial Counseling

☐ Food Stamps

☐ Public Assistance

☐ SSI

☐ Other:

Counseling

☐ Adolescent

☐ Employment

☐ Family

☐ Genetic

☐ Housing

☐ Marital

☐ Special

☐ Other:

Medical/Health

☐ Assessment

☐ Dental Services

☐ Diagnostic/Advisory Clinics

☐ Equipment/Devices

☐ Clinical Services

☐ Home Health Care

☐ Hospitalization

☐ Immunizations

☐ Mental Health Services

☐ Prenatal Care

☐ Prescription Drugs

☐ Primary Health Care

☐ Screening

☐ Substance Abuse Treatment

☐ Women, Infants, and

Children (WIC) Program

☐ Other:

Other

☐ Adult Education

☐ Child Care Resource Center

☐ Family Support Center

☐ Home Visiting Program

(Please specify)

☐ Housing

☐ Legal Services

☐ Parent Education

☐ Recreation Program

☐ Support Group

☐ Other:

SERVICE LINKAGE PROVIDERS

Provider Name: Provider Name:

Phone/E-mail: Phone/E-mail:

Provider Name: Provider Name:

Phone/E-mail: Phone/E-mail:

STRATEGIES TO HELP SERVICE LINKAGES FOR THE FAMILY

PAYMENT SOURCES (Check all that apply.) PERSON(S) INVOLVED TO SECURE SERVICE LINKAGES

☐ Medicaid Managed Care (MCO)

☐ Medicaid Fee for Service

☐ No Fee

☐ Private Health Insurance

☐ Parent: Full Payment

☐ Parent: Sliding Fee

☐ Other:

Name: Name:

Title: Title:

Phone: Phone:

E-mail: E-mail:


Revised 07/13


Revised 07/13

PART VI – AUTHORIZATION(S)

PARENT/GUARDIAN/SURROGATE CONSENT

I/We have had the opportunity to participate in the development of this Individualized Family Service Plan (IFSP) and

have been provided reasonable notice of the IFSP meeting.

I/We have been informed of my/our parental rights under this program through receipt of the Families Have Rights

Procedural Safeguards Notice.

The early intervention services will be provided as described in the IFSP. I/We understand that the IFSP will be

reviewed at least every six (6) months.

I/We understand that my/our consent is voluntary and that I/we may revoke consent at any time.

I/We understand the records will not be released without my/our signed and written consent except under the

provisions of the Family Education Rights and Privacy Act (FERPA). This law allows the release of early intervention

records to participating agencies in the early intervention system.

I/We have been informed of the determination(s) of the IFSP team in my/our native language or other mode of

communication.

This plan reflects the outcomes that are important to my/our child and family.

I/We agree for the Strong Start Program to bill our child’s public health insurance (Medicaid) for the early intervention

services we receive and understand that we will not be charged a co-pay or deductible. I also understand that I may

withdraw consent to disclose personally identifiable information to public insurance for billing purposes.

I/We understand the plan and parental rights and give permission to implement

☐ all services or ☐ the following services as stated in this IFSP:

Parent(s)/Guardian/Surrogate Signature Date


Revised 07/13

PART VII – MY CHILD’S TRANSITION INFORMATION

TRANSITION PLANNING MEETING

TRANSITION PLANNING MEETING DATE:

CONSIDERATION OF ELIGIBILITY FOR PRESCHOOL SPECIAL EDUCATION AND RELATED SERVICES (PART B)

☐ Parents wish to consider Part B eligibility. ☐ Parents DO NOT wish to consider Part B eligibility.

Strong Start (Part C) under the federal Individual with Disabilities Education Act is required to release limited contact information (parent’s name, child’s name, address, telephone numbers and date of birth) as a way to notify District of Columbia Public Schools of your child’s potential eligibility for special education programs and services when your child turns 3 years old.

COMMUNITY SERVICES

Is the family being referred to community services? ☐ Yes ☐ No If YES, check the services that apply.

Developmental/Medical/Health:

☐ Developmental Therapies

(other than Part B)

☐ Equipment/Devices

☐ Home Health Care

☐ Immunizations

☐ Mental Health Services

☐ Primary Health Care

☐ Women, Infants, and Children

(WIC) Program

Child Care/Enrichment:

☐ Camps

☐ Family Day Care

☐ Group Child Care

☐ Even Start

☐ Head Start

☐ Play Group

☐ Preschool Program:

☐ Public

☐ Private

☐ Recreation Program

Family Support:

☐ Family Support Center

☐ Home Visiting Program

(Please specify)

☐ Parent Education

☐ Support Group

☐ Other:

Other Community Services:

TRANSITION PLANNING MEETING NOTES/FUTURE STEPS

Activities Action Steps/Activities Timelines Person(s) Responsible

☐ Discuss preschool options

(including transition to Part B)

☐ Discuss referral for

reassessment

☐ Obtain parental consent to

release information to LEA

☐ Schedule transition conference

☐ Invite LEA or other community

service provider, family, and other appropriate parties to transition conference

☐ Other:


Revised 07/13

TRANSITION CONFERENCE

TRANSITION PLAN

TRANSITION CONFERENCE MEETING DATE:

(Note: Use Transition Conference Signature Page to document attendance/participation of team members)

EXPLANATION FOR MEETING DELAY

If the Transition Conference is held after the child has reached 33 months of age, check the response below that provides an explanation. (Check only one.)

☐ Attempts to contact family were unsuccessful.

☐ Child was referred at 31.5 months of age or later.

☐ Family requested to reschedule or delay the meeting.

☐ Other:

Current services (check as appropriate)

☐ Occupational Therapy minutes per ☐ wk ☐ mo ☐ Audiology Services minutes per ☐ wk ☐ mo

☐ Physical Therapy minutes per ☐ wk ☐ mo ☐ Home Visiting minutes per ☐ wk ☐ mo

☐ Speech/Lang. Therapy minutes per ☐ wk ☐ mo ☐ Feeding Therapy minutes per ☐ wk ☐ mo

☐ Special Instruction minutes per ☐ wk ☐ mo ☐ Other

☐ Vision Services minutes per ☐ wk ☐ mo minutes per ☐ wk ☐ mo

Transition Planning Requirements Action Steps/Activities Person(s) Responsible Date to be Completed

A) Discuss future placements for your child including preschool services under Part B; Head Start; child care and other community services.

B) Transfer additional assessments/evaluations and current IFSP to the LEA (with parental consent).

C) Discuss training opportunities for parents on future placements and other transition matters.

D) Identify activities to help your child adjust to the new program setting.

E) LEA will obtain parental consent to conduct an initial evaluation (Eligibility for Part B services).

F) Discuss potential date for the Individualized Education Program (IEP) meeting (IEP must be developed and implemented by age 3).


Revised 07/13

TRANSITION CONFERENCE – SIGNATURE PAGE

The following individuals participated in this Transition Conference:

Print Name/ Role Signature Date

Method of Participation Agency

Informed Consent by Parents/Guardians

☐ I have received a written copy and verbal explanation of my rights from Strong Start.

☐ I participated fully in the Transition Conference and development of the action steps and activities.

Parent(s)/Guardian Signature Date

Parent(s)/Guardian Signature Date

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