Confidential Early Intervention Program - IFSP Web

1 ConfidentialEarly Intervention ProgramStudent:Janie SmithDate Notice:School:Demo ElementarySchool District:Demo DistrictParents:Sally SmithInitial IFSPC hild's Name:Janie SmithPhone:Child's Birthdate:2009-05-01 SSN:222-77-7788 Age:2 Medicaid#999888333-12 Referral to Early Intervention :where does this come from?Address:222 East Second Street Pall, NE 65789 Family's Language of Consent for Evaluation:10/26/2011 Additional Language Choice:NoneFamily would like an interpreter:Date MDT:11/04/2011 Parent(s) / Guardian1. Sally SmithRole:ParentHome Phone:Work Phone:Address:222 East Second Street Pall, NE 68789 Service Coordinator / Case Manager InformationIf you have any questions about this plan or any of the people working with your child, please call the person listed as the Services Coordinator / Case :Sue BainterPhone:402-471-1860 Agency:Address:IFSP Meeting DatesTypeSecondary RoleDateDate SentInitialNone11/04/2011 IFSP Previous Meeting DatesTypeDateDate SentNo previous meeting dates Rev 11/98 (57060)Student: Janie Smith | School: Demo Elementary | DOB.

2 2009-05-01 | SRS Student ID #1384739 NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page1 SAMPLEC onfidentialPrevious IFSPsNo previous IFSPs to Concerns And Desired Priorities11/04/2011 Sally would like Janie to use more words and maybe even some phrases that are understandable to someoneoutside of their immediate wants to take some night classes. She is not sure yet what she wants to do for a wants to use a Services Rev 11/98 (57060)Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739 NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page2 SAMPLEC onfidentialPrevious IFSPsNo previous IFSPs to And Family Strengths11/04/2011 Janie likes to be around other children and goes to the local daycare 3 mornings per likes to play with babies and her older sister's barbie says that about a fewmonths ago, she could not understand anything Janie would say but could figure out whatshe wanted by having Janie take her to what she wanted.

3 She doesnt know why she can understand a few wordsnow, but no one else has made an appointment to talk to the local community college about possible coursework. Sally's Mom livesnearby and Janie and the family see her Rev 11/98 (57060)Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739 NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page3 SAMPLEC onfidentialInitial IFSPC hild's Present Levels of DevelopmentPrevious IFSPsNo previous IFSPs to - Date / Current Abilities11/04/2011 Janie can see things across the room on the floor or table.

4 She gets around the house and daycare safely. She seesand recognizes pictures in books because she tries to say IFSPsNo previous IFSPs to - Date / Current Abilities11/04/2011 Janie passed her newborn hearing screen and Mom has no current concerns. Janie has only had one ear infectionand can hear Mom calling her from across the house or when she is IFSPsNo previous IFSPs to - Date / Current Abilities11/04/2011 Janie has been very healthy. She recently got her H1N1 IFSPsNo previous IFSPs to Skills - Date / Current Abilities11/04/2011 Janie likes to "take care" of babies and puts them in blankets.

5 She pretends to feed them with a bottle. She also likesto play with dishes and stacks them up as well as pretending to eat from them. Janie likes to do puzzles with her oldersister. She also likes to play barbies if her sister lets her. Janie loves books, especially ones about animals and bringsbooks to her family to read to her. She points to pictures and if Mom says the name, Janie will sometimes saysomething that is not understandable, other times she smiles or laughs. She tries to make animal sounds too. Janiefollows routine directions from Mom and also will go to her room, the bathroom, to the car, etc.

6 If she hears Mom oranother family member talking about Rev 11/98 (57060)Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739 NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page4 SAMPLEP revious IFSPsNo previous IFSPs to Skills - Date / Current Abilities11/04/2011 Janie says a few words that mostly only Mom can understand: "da" for her name when asked, "dee" when asked howold she is; also "owie", "mommy", "mama" (for gramma). She occasionally tries to put a couple words together "I ite"for "I write", "ho baba" for "hold baby".

7 Sometimes Janie will take Mom or another family member by the hand to showwhat she wants but other times she gets frustrated and will cry or IFSPsNo previous IFSPs to Skills - Date / Current Abilities11/04/2011 Janie loves music and likes to dance to it. She can even hum some of her favorite songs. She likes to be outside andchase the cat around. She plays well with the other children at daycare - usually this is alongside if in the house, butalso will do puzzles with other children her age or slightly older, or simple games. She also loves to go to Grandma' IFSPsNo previous IFSPs to Skills - Date / Current Abilities11/04/2011 Janie is a really good eater and usually eats just about anything that Mom gives her.

8 She drinks from a regular cupand uses silverware. She can undress herself and gets her pajamas on at night. She is very nearly potty trained andhas just started to tell Mom when she has to go "pe".Previous IFSPsNo previous IFSPs to Motor Skills - Date / Current Abilities11/04/2011 Janie likes to scribble on paper. She picks up small pieces of food using her thumb and index finger. She uses theknobs on puzzles which are pretty small. She likes to color in her coloring book if her sister is doing this IFSPsNo previous IFSPs to Motor Skills - Date / Current AbilitiesDraftEI-1 Rev 11/98 (57060)Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739 NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page5 SAMPLE11/04/2011 Janie can kick a ball and tries to peddle on her big wheel.

9 Sometimes she can and other times she might just pushwith her feet. She runs, jumps, and climbs on furniture. She can go down the slide by herself at the park and likes Rev 11/98 (57060)Student: Janie Smith | School: Demo Elementary | DOB: 2009-05-01 | SRS Student ID #1384739 NEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page6 SAMPLEC onfidentialGoal #1 Goal / OutcomeJanie will spontaneously use words and phrases during mealtime, while reading books, and when playing babies/Barbies with hersister or other children at home and daycare . We will know she can do this when all family members and other children canunderstand her words and phrases and she does not have to show them what she wants/means.

10 This should happen at least onceper day at home and / Family strengths and resources related to this goal:Janie loves playing with babies when at home and daycare . She also likes to play Barbies with her likes to have books read to her and sometimes tries to repeat something she hears Sallysay after Janie has pointed to has a few words and 2 word phases that are meaningful and Sallycan understand is a good eater and the family eats the evening meal will be done / by whom:Sallyand daycare provider will:* Be sure to talk about what they are doing in short words/phrases that match Janie's current level of communication.