Infant & ToddlerConnection of Virginia

Infant & Toddler Connection of Virginia Individualized Family Service Plan (IFSP)

A county in VA

Section I: Child and Family InformationChild’s Name: Joe Reed Date of Birth: 11/21/2013

Gender: XM F Child’s County or City of Residence: A county in VA

IFSP Date: 10/16/2015 Initial

Annual #     Date 6 mo. Review Due: 4/16/2016

Date(s) Review(s) Completed: 4/4/2016 5/16/2016 7/15/2016                  

Family’s Primary Language and/or Mode of Communication: English Child’s (if different)      

Medicaid Number (optional):      

Parent’s and/or Other Family Member’s Name, Address, Phone And Other Contacts:

Jane and Mike Reed123 Happy Street Happyville, VA 23234804 555-1212

Dr. BLBC Medical Center5555 Pine StreetHappyville, VA 23234804 555-1212

Service Coordinator’s Name, Agency, Address, Phone Number, Email and Fax Number:Mary Hill12345 Circle St.Happyville, VA 23234804 555-1234

Early Intervention services are provided to eligible children and their families in compliance withPart C of the federal Individuals with Disabilities Education Act.

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Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Section II: Team Assessment

A. Referral Information, Medical History, Health Status:

At intake, on 9/30/2015, mom reported that Joe is a 22 month old little boy who was referred to early intervention by his pediatrician for speech concerns. Joe lives with his mother, father, and little brother. Mom is 29 and Dad is 31 and both are in good health. Mom stated that both of her parents wear eyeglasses and she had weak eye muscle as a child which required a patch and corrective lenses in high school. Mom began prenatal care at about eight weeks of pregnancy. Mom also reported that she took Phenergan, Zofran, Antacid, and Tylenol during pregnancy and also took an antibiotic to treat a UTI.Joe was born full term, vaginally, weighting six pounds and nine ounces. Joe was released after a standard hospital stay and passed his newborn hearing screening. Mom stated that Joe was seen by an ophthalmologist when he was under a year for concerns with a “floating eye,”, but this self-corrected without any ongoing concerns. Joe is now only seen by his pediatrician.

B. Daily Activities and RoutinesEarly intervention supports and services are designed to fit into your family’s life and take place as part of the daily activities of your child.

• Things your child does every day (or every week)• Activities your child enjoys• Activities or times of the day that are difficult or frustrating for you or your child (if any)• Places you and your child go (or would like to go)• Things you would like to do as a family, but cannot do because of your child’s needs (if any)

Joe is at an in-home daycare Monday through Friday. Joe wakes up each morning around 7:30 am and goes to bed between 7:30-9:00 pm. Mom states that it takes Joe and hour or more to fall asleep each night. Joe is sleeping though the night. Mom reported that Joe takes naps inconsistently and will go down for nap at daycare, but other days he will skip it.

C. Family Concerns, Priorities, and Resources:To best support your child and family, it is helpful to understand what is 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.

Voluntary!Your child can still receive services if this section is not completed._____ Parent initial if choosing not to include this information in

the IFSP.

MY FAMILY’S CONCERNSConcerns I have (if any) about my child’s health and/or development. Information, resources, and/or supports I need or want for my child and/or family.Mom’s main concern is speech development.

MY FAMILY’S PRIORITIESThe most important things for my child and/or family.Mom stated that she would like to work with Joe on communication.

MY FAMILY’S RESOURCESResources that my child/family has for support, including people, activities, programs/organizationsThe people who live in the household are Mom, Dad, and Joe. There is a baby on the way. The family has private insurance.

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Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia

Section II: Team AssessmentD. Summary of Your Child’s Development (Comparisons to same age peers are based on your child’s

chronological age; the comparisons are not adjusted for prematurity. At the annual IFSP, this section will also document new skills your child has shown since the first IFSP.)

Social/Emotional Skills, including social relationships: This area involves how your child interacts with adults and with other children, including how your child communicates his or her feelings.Joe is a friendly and independent little boy. He preferred to stay close to Mom and Dad at the beginning of our visit, but was able to move away to play after about five minutes. Joe responds occasionally when his name is called. Mom and Dad are concerned that Joe does not come when his name is called, because they feel it is a safety issue. Mom says she will usually just grab Joe’s hand when they are out in the community together because he does not respond to his name or commands for safety (i.e. “Hold my hand.”). Mom stated that if a baby is crying then Joe will try to comfort them. Joe is making a grunting sound to get Mom and Dad’s attention. Joe will come to Mom and Dad for hugs and kisses, and also to engage them in social play. Joe will throw a ball back and forth, but likes games like “Chase” or when Dad tosses or flips him in the air. Joe will wiggle his body to tell Dad he wants to be tossed and flipped again. Joe enjoys engaging in parallel play with others and will sometimes use jargon to try and interact. Mom reported that Joe tends to be aggressive toward other people. Joe will guard his toys my moving them away from others or shaking his head “no,”, to tell a person to leave his toys alone. Joe demonstrates brief eye contact during play and interactions with others. He will use sustained eye contact during requests. Mom is concerned about Joe’s tantrums. Joe will fall to the floor and cry when he does not get his way or when Mom leaves him at daycare. Mom says these behaviors are shorter at home, lasting about five minutes, and longer at daycare lasting about 15 minutes. Mom and Dad both agree that Joe has difficulty with transitions. Dad says that Joe needs to be introduced to another activity before he changes to the new activity. If they attempt to immediately change activities with Joe, it upsets him. At daycare Joe has difficulty moving from one activity to the next with his peers.

Child’s Development in Relation to Other Children the Same Age:Joe shows occasional use of some of some age expected skills. He has more skills of a younger child in this area.

Acquiring and Using Knowledge and Skills, including early language/communication: This area involves how your child learns, including development of imitation, thinking, remembering, problem solving skills and using language (including gestures) to communicate what he or she knows and understands.Joe will occasionally use the word “bye” and wave. Mom stated that Joe does not have any words at this point. Joe is using a lot of jargon and babbling during playtime and mealtimes. Joe is using grunting sounds to communicate basic needs and wants. Mom stated that she has heard Joe say “mama,”, but not to get her attention. If Joe wants something, or needs to get Mom or Dady’s attention he will grunt. If it is around dinnertime and Joe is grunting he is hungry. If he is grunting around bedtime, then he is tired and wants to be comforted. Mom stated that there is no variation to indicate different wants/needs. Joe will sometimes reach for an item he would like or move toward the item. He will whine or look to Mom or Dad to make a request for food, a toy, or an activity. Joe will throw food when is done eating. Mom and Dad are in the process of teaching Joe to hand them his food when he is finished eating. He is not pointing to objects that interest him in his environment. Mom says Joe will watch cars pass by their house, but does not point to show her. He will bring toys to Mom or Dad if a toy is “broken.” Joe prefers to imitate gestures versus sounds and Dad says Joe will imitate gestures to children’s nursery rhymes. Dad says Joe loves to dance and make sounds when he hears music. He will also imitate Mom and Dad completing household jobs like sweeping and wiping off tables. Joe will imitate a few sounds he hears in his day or Mom once heard Joe repeat “nanan” at the store when Dad pointed to the bananas. Mom reported that Joe also likes to roll his tongue and make different noises. Joe did stop to move the therapist’s hand out of the way so he could continue coloring. Mom and Dad reported that Joe easily “tunes out” voices and environmental sounds when he is focused during play. He likes to play with blocks, toy cell phones, and cars. Joe is using pretend play with the phone and pretending to drink from a cup. Joe loves to look at books and will point to pictures on request. He is also beginning to point to different body parts on request. Joe learns by watching others. Joe is not consistently following a one-step direction. . Dad says Joe will sometimes follow through with a command if he changes the intonation of his voice. Dad uses a firm voice and this will get a response from Joe.

Child’s Development in Relation to Other Children the Same Age:Joe shows occasional uses of some age expected skills. He has more skills of a younger child in this area.

Use of Appropriate Behaviors to Meet Needs: This area involves how your child lets you know what he or she needs, how your child gets where he/she wants to go, and how your child is learning to take care of himself/herself, like Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 3 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Section II: Team Assessmentdressing and undressing, feeding himself/herself, sleeping through the night, and using the toilet. This area also includes how your child is learning to follow directions about safety.Joe is an active little boy that will walk, run, climb, and jump independently throughout his home and daycare environment. He is also able to walk up and down stairs independently. Dad states Joe attempts to catch a ball and will throw one overhand. Joe was noted on the assessment visit to grasp a small crayon with his thumb and fingers and color on paper. He will imitate adults making dots on the paper. He is able to pick up small pieces of food with a thumb and index finger and bring it to his mouth to eat it. In play he will stack small blocks, put pegs in a peg boards, and can put shape puzzles together. Joe has become increasingly picky in his food choices recently. He will eat peanut butter and jelly sandwiches, pancakes, beans and rice, and cookies. He likes tart foods or drinks such as lemonade, even though he may make a face to indicate it tastes sour. Mom stated that Joe has stopped eating vegetables and they often have to hide the vegetables in other foods in order to get Joe to eat them. He also has started to spit out meat and the family thinks this may be due to the texture of the meat. Joe also frequently puts too much food in his mouth and has to be monitored closely during mealtimes. Joe will drink from a sippy cup, straw, and an open cup with minimal assistance. He occasionally takes a nap in the afternoon and he sleeps through the night. Joe does take several hours to fall asleep in the evening. Joe is not yet using the toilet. He will assist his parents with dressing. .

Child’s Development in Relation to Other Children the Same Age:Joe shows many age expected skills. Joe also continues to show some skills that might describe a younger child in this area.

Section III: Age & Developmental Levels

Age: 22 mos. Adjusted Age       Cognitive Scattered skills 18-23 mos.

Receptive Language Scattered skills 14-19 mos.

Adaptive/Self-Help 18-24 mos. Gross Motor 24 mos.

Expressive Language Scattered skills to 14 mos.

Social-Emotional 15 mos. with scattered skills up to 22 mos.

Fine Motor 18-24 mos.

Hearing:Results of Virginia Part C Hearing Screening tool: No need for referral indicated Monitor ReferStatus (ear-specific information whenever possible):      Vision:Results of Virginia Part C Vision Screening tool: No need for referral indicated Monitor ReferStatus (eye-specific information whenever possible):      

Assessment Sources: Assessment Tools:

Hawaii Early Learning Profile (HELP) HELP Strands       Early Learning Accomplishment Profile (E-LAP) Family Assessment Receptive Expressive Emergent Language Scale (REEL), Michigan       Battelle Developmental Inventory (BDI or Battelle). Rossetti Infant-Toddler Language Scale

Review of birth records and/or pertinent medical records less than six (6) months old from the primary care physician and other sources related to the child’s current health status, physical development (including vision and hearing), and medical history. Records Reviewed:       Ongoing Assessment (for annual team assessment) Parent Report Formal/informal observation Informed clinical opinion Other

Specify other: ASQ and word list

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Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia The following people participated in the assessment for service planning (ASP) (Printed name, credentials, signature, date):

Jane and Mike ReedParent

MH B.S Service Coordinator, Hiccup Parent and Infant Program 10/16/2015Service Coordinator

MH B.S. ServiveDiscipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

CLM M.S., CCC-SLP, Hiccup Parent Infant Program 10/16/2016Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

JA M.ed Developmental Specialist 10/16/2015Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name CredentialsDiscipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name CredentialsDiscipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Information from the following assessments completed outside the Infant & Toddler Connection of Virginia system was used to complete the assessment for service planning (Printed name, credentials, discipline, and organization):N/A                         

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Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia

Section IV: Outcomes of Early Intervention

Outcome (Long-Term Goal) # 1 – Service Coordination (required)In order to help your child and family receive the supports and services you need, your service coordinator will assure: that the IFSP addresses your identified concerns, priorities and resources; the appropriateness and adequacy of supports and services; your satisfaction with supports and services; and that your child’s and family’s rights are protected.

Short-Term Goals Target Date Date Met

Assist your family with the development and ongoing review and revision of the IFSP. ongoing      Provide support and assistance to your family in addressing issues or concerns that emerge over time. ongoing      Provide information and support your family, as needed, in accessing routine medical care for your child. ongoing      Provide supports identified by your family to include resources for:Toddler Activities Handbook 10/16/2015                                                         

Service Coordination Activities (Interventions): Maintain ongoing contact with you for service monitoring Phone calls/personal contacts with your family and with individuals/agencies that provide support, assistance, services. Link your family with appropriate community resources. Assist with problem solving.

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Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Section IV: Outcomes of Early Intervention Date Outcome Added: 7/15/2016Acquisition: Describe skill or behavior desired to be achieved.Context or Setting within Everyday Routines and Activities: Identify routines/activity in which behavior occurs.Criterion for Achievement Over What Amount of Time: Describe frequency/duration/rate for the new skill/behavior stated over a specific time period.

Outcome (Long-Term Functional Goal) #1 Target Date: 10/16/2016 Date met, changed or ended: 7/15/2016

Joe will use a two to three word phrase to indicate his wants, needs, and thoughts to his family, friends, and school staff when participating in daily routines 5X’s per day for two consecutive weeks.

Learning opportunities and activities that build on your child’s and family’s interests and abilities:Playtime, mealtime, daycare setting, and community outings

Short-Term Goals Target Date Date Met1. Joe will be able to follow one and two step directions from his family or childcare teachers to get ready for activity changes, clean up times, or when playing with toys during his day, 2-3 times per day for two consecutive weeks. 10/16/2016      2. When given a choice of 2-3 items, Joe will verbalize to his family or childcare teachers what he would like, using a 2-3 phrase during snack, mealtime, or playtime 3 times per for two consecutive weeks. 10/16/2016      3. Joe will be able to answer a question from his parents, family, or childcare teachers with a “yes” or a “no” response or a one to two word phrase, during daily activities, 2-3 times per day for two consecutive weeks. 10/16/2016      4. Joe will use signs, words, or phrases to tell his mom, dad, or caregivers when he has to go potty, 1-2 times each day for two consecutive weeks. 10/16/2016      5. Joe will take turns during a play activity with a partner, by looking to their eyes/face as they play, and participate in 5-6 turns, 2 times per day for two consecutive weeks. 10/16/2016      6. Joe will move from on activity at school to the next with one prompt directed to the group, using gestures or picture cues as needed at least 2 times per day for two consecutive weeks. 10/16/2016      7. Joe will tell his family about a daily event at the end of his day, using picture cues as needed, 3 times per week for two consecutive weeks. 10/16/2016                                                                                           

Interventions (Treatment procedures and/or modalities)Coaching and modeling intervention strategiesDevelopmental play and language skillsSound imitation games/ Experience Book

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Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Section V: Services Needed to Achieve Early Intervention Outcomes

ENTITLED SERVICEFREQUENC

Y(# x/wk/

month/once)

LENGTH(# min/visit)

GRO

UP (G

) / IN

DIVI

DUAL

(I)

METHODS**

(a,b,c,d)

NATURAL ENVIRONMENT/ LOCATION(Must be a natural

setting unless justified below)

PAYMENT

1 Family Fee2 Insurance3 Medicaid4. State Funds5. Local Funds6. Part C

PROJECTED START DATE

PROJECTEDEND DATE

ACTUALEND DATE

1. Service Coordination

1/X a month 15 * G B

Home, phone, natural

environment

6 4/4/2016 10/15/2016      

2. Developmental Services

1/X a week 60 I A

Home, daycare,

community, etc.

6 4/29/2016

10/16/2016

3.        4.        5.                                                        6.                                                        7.                                                        8.                                                        * This is the minimum frequency and length of direct contact from your service coordinator. The frequency and length of service coordination actually provided will vary since service coordination is an active, ongoing process that changes based on your family’s priorities and needs.** Methods: a = Coaching, including hands-on as appropriate b = Consultation c = Assessment

d = Provision of assistive technology device

Justification of why early intervention outcomes can’t be achieved satisfactorily in a natural setting and a plan with timelines and supports necessary to return early intervention services to natural settings:n/a

Reason for later projected start date - For each service that is planned to start more than 30 calendar days after the family signs the IFSP, indicate whether the reason is family scheduling preference, team planned a later start date to meet child and family needs, or other:n/a

VI. Other Services (Services needed, but not entitled under Part C - including medical services such as well baby checks, follow-up with specialists for medical purposes, etc.)

SERVICE PROVIDER LOCATION STEPS TO BE TAKEN TO ASSIST IN SECURING SERVICES

Pediatrician Dr. B The Medical Center Established Patient

                                                                                                                                          

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 8 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia

Section VII: Transition PlanningThe following information about transition is discussed beginning at the initial IFSP meeting:o Transition happens when your child leaves early intervention. The planning on this page will help you and your child move

smoothly from early intervention to whatever comes next for your child.o Options after early intervention (examples: community programs like neighborhood nursery schools, Head Start, early childhood

special education through the public schools).o Possible timing of transition

When your child reaches age level in all developmental areas and meets no other eligibility requirements for early intervention When your child reaches his/her third birthday, which is the end of eligibility for early intervention When and if your child begins early childhood special education services through the public schools (between age 2 and 3), if

you are interested in those services. Children may not be served in early intervention and early childhood special education through the public schools at the same time.

This information was discussed on 10/16/2015 (date) by__LB____ (initials of service coordinator)

Important Dates for Transition Planning:4-1-16 - target date for notification and referral to determine eligibility if you are interested in early childhood special education services through your local school system (referral must occur at least 90 days before the anticipated date of transition and must occur by April 1 of the year your child turns 2 by Sept. 30 if you want your child to begin school on the first day of the next school year).11-21-16 (date of child’s 3rd birthday) – date on which your child is no longer eligible to receive early intervention

Transition PlanThe transition activities completed will depend on your transition plans and family preferences.

Transition Steps/Activities

Targ

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ate

Dat

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ompl

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Initi

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Pers

on

1. Community Options: Help your family explore community program options, which may include early childhood special education services, for your child[a.] Provide information, including program contact information, about community options

following early intervention, as desired by your family. Information provided on the following programs: ECSE, private therapy, preschool, aba ABA

a.[b.] Arrange for visits to programs, as desired by your family. Programs visited: N/Ac. Other steps/activities (e.g., if you are interested, provide names of other families, with

their permission, who have transitioned to programs you are considering): N/A

5/16/2016 5/16/2016 LP

2. Notification and Referral to the Local School Division and Virginia Department of Education: At least 90 days before the anticipated date of transition and before April 1 of the year your child turns 2 by Sept. 30 if you want your child to begin school on the first day of the next school year –[a.] Send your child’s name, date of birth and your contact information (name, address, phone

number) to the Chesterfield County Public school division and Virginia Department of Education no earlier than N/A unless you disagree. Sending this information helps the school system to know who in the community may be eligible for special education services and is a referral to the local school division. I do not want my child’s name, date of birth and our contact information sent to the

local school division and Virginia Department of Education for notification and referral ____N/A___________________ (parent initials and date)

I have changed my mind and agree to have this information sent to the local school division and Virginia Department of Education ___N/A_____________ (parent initials and date)

a.[b.] Date notification and referral sent to the local School Division: 4/15/2016 to VDOE: N/Ab.[c.] With your consent on a release of information form, send specific information about your

child to the local school division (e.g., most recent eligibility determination and assessment reports, IFSP, etc.). Your consent obtained on release of information form on 4/4/2016 (date) Date information sent 4/4/2016

N/A N/A    

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Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia

Transition Steps/Activities

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Initi

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Pers

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Com

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3. Support to Enroll in Other Programs: Help your family enroll in a community program(s), other than the local school division, that you are interested in for your child, as available.a. Help with getting and filling out paperwork and/or completing other steps necessary to

enroll in the desired program: N/Ab. If needed, with your consent on a release of information form, refer your child and send

specific information about your child to the future service provider or program (e.g., most recent eligibility determination and assessment reports, IFSP, etc.) Your consent obtained on release of information form on N/A (date) Referral sent to N/A (program) on N/A (date) Date information sent: N/A

c. Other steps/activities: N/A

N/A N/A N/A

4. Transition Planning Conference: At least 90 days, and up to 9 months if everyone agrees, before your child’s anticipated date of transition –If your child might be eligible for early childhood special education services, plan for a transition conference between you, your service coordinator, and someone from your school division.a. Parental Prior Notice form provided on 5/16/2016 (date)b. You approve/ do not approve conference.c. If you approve the conference, service coordinator ensures scheduling of conference and

participation by required parties: Transition conference held on 5/16/2016 (date) The following participated: (You - required), (early intervention- required),

(school division - required), (other N/A), (other      )

5/16/2016 5/16/2016 LP

5. Transition Services: Once your transition plans have been determined, help your child and family prepare, as desired by your family, for changes in supports and services so you can move smoothly out of early intervention and, if appropriate, into a new programa. Your child will transition to       on       (projected date)b. Help your child and family get ready to transition out of early intervention and, if

appropriate, into a new program/setting by:     

N/A N/A N/A

6. Exiting Early Intervention: Discharge your child from the local Part C system before his/her 3rd birthdaya. Parental Prior Notice form is signed Yes Nob. Date of discharge/closure N/A

N/A N/A N/A

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Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Section VIII: IFSP AGREEMENTParental Consent for Provision of Early Intervention Services:

I have received a copy of family rights and information about family cost share under Part C of IDEA (Notice of Child and Family Rights and Safeguards Including Facts about Family Cost Share) along with this IFSP. These rights and payment policies have been explained to me and I understand them. I participated in the development of this IFSP and I give informed consent for the Infant & Toddler Connection of Virginia system and service providers to carry out the activity(ies) listed on this IFSP.

Consent means I have been fully informed of all information about the activity(ies) for which consent is sought, in my native language (unless clearly not feasible to do so) or other mode of communication; that I understand and agree in writing to the carrying out of the activity(ies) for which consent is sought; the consent describes that activity(ies); and the granting of my consent is voluntary and may be revoked in writing at any time.

I understand that the Infant & Toddler Connection allows parents to choose a specific service provider agency or service provider. The Infant & Toddler Connection will make available the IFSP service(s) needed by my child in a timely manner even if it is not with the provider of my first choice. If I wish to select a specific provider, then my consent to the IFSP service will begin once that provider is available and then services will be provided in a timely manner.

I understand that I may decline a service or services without jeopardizing any other early intervention service(s) my child or family receive through the Infant & Toddler Connection of Virginia system.

I understand that my IFSP will be shared within the local Infant & Toddler Connection of Virginia system, including with providers involved in assessment and/or in the development and/or implementation of this IFSP.

Signature on file 10/16/2015Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Other IFSP Participants (Printed name, credentials, signature, date):LB B.S., Service Coordinator 10/16/2015Discipline: Service Coordinator

CL, M.S., CCC-SLP 10/16/2015Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

JA M.Ed., Developmental Specialist 10/16/2015Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name CredentialsDiscipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name CredentialsDiscipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name CredentialsDiscipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

The following individuals participated electronically or in writing (specify which):          

Translator/Interpreter (if used):      

The following related documents are attached:      

Copies to: Pediatrician

Physician Certification (required in order to bill insurance): I certify and approve that       services, as described in the IFSP, are medically necessary for this child.

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 11 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Section VIII: IFSP AGREEMENT

Signature Credentials Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 12 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Section IX: IFSP Review RecordPurpose of Review: 6 month Review Upon Request by: Team Review Date: 4/4/20116

Summary (Include rationale for any changes resulting from this review):A transition plan was developed. A 90 day transition meeting was offered and scheduled for May 16 at 1:00

Change(s): Projected Start Date For Change:No changes in services 4/4/2016                                 

Parental Consent

I have received a copy of family rights and information about family cost share under Part C of IDEA (Notice of Child and Family Rights and Safeguards Including Facts about Family Cost Share) along with this IFSP Review Record. These rights and payment policies have been explained to me and I understand them. I participated in the development of this IFSP Review and I give informed consent for Infant & Toddler Connection of Virginia system and service providers to carry out any changes listed on this IFSP Review Record.

I understand that the Infant & Toddler Connection allows parents to choose a specific service provider agency or service provider. The Infant & Toddler Connection will make available the IFSP service(s) needed by my child in a timely manner even if it is not with the provider of my first choice. If I wish to select a specific provider, then my consent to the IFSP service will begin once that provider is available and then services will be provided in a timely manner.

Consent means I have been fully informed of all information about the activity(ies) for which consent is sought, in my native language (unless clearly not feasible to do so) or other mode of communication; that I understand and agree in writing to the carrying out of the activity(ies) for which consent is sought; the consent describes that activity(ies); and the granting of my consent is voluntary and may be revoked in writing at any time.

I understand that I may decline a service or services without jeopardizing any other early intervention service(s) my child or family receives through the Infant & Toddler Connection of Virginia system.

I understand that my IFSP will be shared within the local Infant & Toddler Connection system, including with providers involved in assessment and/or development and/or implementation of this IFSP.

Signature on File 4/4/3016Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 13 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Section IX: IFSP Review Record

Review Date: 4/4/16If services increased on this IFSP review and my child is covered by private insurance:

My insurance should be billed for covered services. Unless my monthly cap is $0, I agree to continue paying for any applicable co-payments, deductibles and/or non-covered services in the manner indicated in the Charges section on the Family Cost Share Agreement form. I understand I can cancel this consent at any time by giving written notice to my child’s service coordinator.

My insurance should no longer be billed for covered services. Unless my monthly cap is $0, I agree to pay for services in the manner indicated in the Charges section on the Family Cost Share Agreement form. I understand that I must complete and sign a new Family Cost Share Agreement form.

I understand I can contact my service coordinator if I have questions about use of insurance or the payment arrangements on the Family Cost Share Agreement form.

Signature on file 4/4/2016Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Other IFSP Participants (printed name, credentials, signature, date):LP, MSW, CIP, 4/4/2016

Discipline: Service Coordinator

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other           

The following individuals participated electronically or in writing (specify which):               

Physician Certification (required in order to bill insurance): I certify and approve that       services, as described in the IFSP, are medically necessary for this child.

Signature Credentials Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 14 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Addendum(Refer to corresponding number in Section V of the IFSP for service details)# Service SERVICE PROVIDER (Name, agency, address, phone number) Current?1 Service

CoordinationCarefree Infant Program, 222 Content Ave, Happyville, VA 23234 804 555-1234 N      N      N

2             N      N      N

3             N      N      N

4             N      N      N

5             N      N      N

6             N      N      N

7             N      N      N

8             N      N      N

I was given the opportunity to choose from among provider agencies who work in my local system area and who are in my payor network. I may request to change service providers at any time by contacting my service coordinator.

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 15 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Section IX: IFSP Review RecordPurpose of Review: 6 month Review Upon Request by: Team Review Date: 4/14/20116

Summary (Include rationale for any changes resulting from this review):A transition plan was developed. A 90 day transition meeting was offered and scheduled for May 16 at 1:00

Change(s): Projected Start Date For Change:End Speech Services and add Weekly Developmental Services 4/19/2016                                 

Parental Consent

I have received a copy of family rights and information about family cost share under Part C of IDEA (Notice of Child and Family Rights and Safeguards Including Facts about Family Cost Share) along with this IFSP Review Record. These rights and payment policies have been explained to me and I understand them. I participated in the development of this IFSP Review and I give informed consent for Infant & Toddler Connection of Virginia system and service providers to carry out any changes listed on this IFSP Review Record.

I understand that the Infant & Toddler Connection allows parents to choose a specific service provider agency or service provider. The Infant & Toddler Connection will make available the IFSP service(s) needed by my child in a timely manner even if it is not with the provider of my first choice. If I wish to select a specific provider, then my consent to the IFSP service will begin once that provider is available and then services will be provided in a timely manner.

Consent means I have been fully informed of all information about the activity(ies) for which consent is sought, in my native language (unless clearly not feasible to do so) or other mode of communication; that I understand and agree in writing to the carrying out of the activity(ies) for which consent is sought; the consent describes that activity(ies); and the granting of my consent is voluntary and may be revoked in writing at any time.

I understand that I may decline a service or services without jeopardizing any other early intervention service(s) my child or family receives through the Infant & Toddler Connection of Virginia system.

I understand that my IFSP will be shared within the local Infant & Toddler Connection system, including with providers involved in assessment and/or development and/or implementation of this IFSP.

Signature on File 4/14/3016Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 16 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia

Section IX: IFSP Review RecordReview Date: 4/14/16

If services increased on this IFSP review and my child is covered by private insurance:

My insurance should be billed for covered services. Unless my monthly cap is $0, I agree to continue paying for any applicable co-payments, deductibles and/or non-covered services in the manner indicated in the Charges section on the Family Cost Share Agreement form. I understand I can cancel this consent at any time by giving written notice to my child’s service coordinator.

My insurance should no longer be billed for covered services. Unless my monthly cap is $0, I agree to pay for services in the manner indicated in the Charges section on the Family Cost Share Agreement form. I understand that I must complete and sign a new Family Cost Share Agreement form.

I understand I can contact my service coordinator if I have questions about use of insurance or the payment arrangements on the Family Cost Share Agreement form.

Signature on file 4/14/2016Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Other IFSP Participants (printed name, credentials, signature, date):LP, MSW, CIP, 4/4/2016

Discipline: Service Coordinator

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other           

The following individuals participated electronically or in writing (specify which):               

Physician Certification (required in order to bill insurance): I certify and approve that       services, as described in the IFSP, are medically necessary for this child.

Signature Credentials Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 17 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Addendum(Refer to corresponding number in Section V of the IFSP for service details)# Service SERVICE PROVIDER (Name, agency, address, phone number) Current?1 Service

CoordinationCarefree Infant Program, 222 Content Ave, Happyville, VA 23234 804 555-1234 N      N      N

2 Developmental Services

Carefree Infant Program, 222 Content Ave, Happyville, VA 23234 804 555-1234 N      N      N

3             N      N      N

4             N      N      N

5             N      N      N

6             N      N      N

7             N      N      N

8             N      N      N

I was given the opportunity to choose from among provider agencies who work in my local system area and who are in my payor network. I may request to change service providers at any time by contacting my service coordinator.

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 18 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia

Section IX: IFSP Review Record

Purpose of Review: 6 month Review Upon Request by: Team Review Date: 5/16//20116

Summary (Include rationale for any changes resulting from this review):A 90 day transition meeting occurred today.

Change(s): Projected Start Date For Change:No changes in services                                 

Parental Consent

I have received a copy of family rights and information about family cost share under Part C of IDEA (Notice of Child and Family Rights and Safeguards Including Facts about Family Cost Share) along with this IFSP Review Record. These rights and payment policies have been explained to me and I understand them. I participated in the development of this IFSP Review and I give informed consent for Infant & Toddler Connection of Virginia system and service providers to carry out any changes listed on this IFSP Review Record.

I understand that the Infant & Toddler Connection allows parents to choose a specific service provider agency or service provider. The Infant & Toddler Connection will make available the IFSP service(s) needed by my child in a timely manner even if it is not with the provider of my first choice. If I wish to select a specific provider, then my consent to the IFSP service will begin once that provider is available and then services will be provided in a timely manner.

Consent means I have been fully informed of all information about the activity(ies) for which consent is sought, in my native language (unless clearly not feasible to do so) or other mode of communication; that I understand and agree in writing to the carrying out of the activity(ies) for which consent is sought; the consent describes that activity(ies); and the granting of my consent is voluntary and may be revoked in writing at any time.

I understand that I may decline a service or services without jeopardizing any other early intervention service(s) my child or family receives through the Infant & Toddler Connection of Virginia system.

I understand that my IFSP will be shared within the local Infant & Toddler Connection system, including with providers involved in assessment and/or development and/or implementation of this IFSP.

Signature on File 5/16/2016Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 19 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Section IX: IFSP Review Record

Review Date: 5/16/2016If services increased on this IFSP review and my child is covered by private insurance:

My insurance should be billed for covered services. Unless my monthly cap is $0, I agree to continue paying for any applicable co-payments, deductibles and/or non-covered services in the manner indicated in the Charges section on the Family Cost Share Agreement form. I understand I can cancel this consent at any time by giving written notice to my child’s service coordinator.

My insurance should no longer be billed for covered services. Unless my monthly cap is $0, I agree to pay for services in the manner indicated in the Charges section on the Family Cost Share Agreement form. I understand that I must complete and sign a new Family Cost Share Agreement form.

I understand I can contact my service coordinator if I have questions about use of insurance or the payment arrangements on the Family Cost Share Agreement form.

Signature on file 5/16/2016Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Other IFSP Participants (printed name, credentials, signature, date):LP, MSW, CIP, 5/16/2016

Discipline: Service Coordinator

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other           

The following individuals participated electronically or in writing (specify which):               

Physician Certification (required in order to bill insurance): I certify and approve that       services, as described in the IFSP, are medically necessary for this child.

Signature Credentials Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 20 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Addendum(Refer to corresponding number in Section V of the IFSP for service details)# Service SERVICE PROVIDER (Name, agency, address, phone number) Current?1 Service

Coordinationsame N      N      N

2             N      N      N

3             N      N      N

4             N      N      N

5             N      N      N

6             N      N      N

7             N      N      N

8             N      N      N

I was given the opportunity to choose from among provider agencies who work in my local system area and who are in my payor network. I may request to change service providers at any time by contacting my service coordinator.

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 21 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia

Section IX: IFSP Review RecordPurpose of Review: 6 month Review Upon Request by: Team Review Date: 7/15/20116

Summary (Include rationale for any changes resulting from this review):Old goals were reviewed and new ones were written.

Change(s): Projected Start Date For Change:Services to remain the sameNew Goals 7/15/2016                      

Parental Consent

I have received a copy of family rights and information about family cost share under Part C of IDEA (Notice of Child and Family Rights and Safeguards Including Facts about Family Cost Share) along with this IFSP Review Record. These rights and payment policies have been explained to me and I understand them. I participated in the development of this IFSP Review and I give informed consent for Infant & Toddler Connection of Virginia system and service providers to carry out any changes listed on this IFSP Review Record.

I understand that the Infant & Toddler Connection allows parents to choose a specific service provider agency or service provider. The Infant & Toddler Connection will make available the IFSP service(s) needed by my child in a timely manner even if it is not with the provider of my first choice. If I wish to select a specific provider, then my consent to the IFSP service will begin once that provider is available and then services will be provided in a timely manner.

Consent means I have been fully informed of all information about the activity(ies) for which consent is sought, in my native language (unless clearly not feasible to do so) or other mode of communication; that I understand and agree in writing to the carrying out of the activity(ies) for which consent is sought; the consent describes that activity(ies); and the granting of my consent is voluntary and may be revoked in writing at any time.

I understand that I may decline a service or services without jeopardizing any other early intervention service(s) my child or family receives through the Infant & Toddler Connection of Virginia system.

I understand that my IFSP will be shared within the local Infant & Toddler Connection system, including with providers involved in assessment and/or development and/or implementation of this IFSP.

Signature on File 7/15/2016Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 22 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Section IX: IFSP Review Record

Review Date: 7/15/2016If services increased on this IFSP review and my child is covered by private insurance:

My insurance should be billed for covered services. Unless my monthly cap is $0, I agree to continue paying for any applicable co-payments, deductibles and/or non-covered services in the manner indicated in the Charges section on the Family Cost Share Agreement form. I understand I can cancel this consent at any time by giving written notice to my child’s service coordinator.

My insurance should no longer be billed for covered services. Unless my monthly cap is $0, I agree to pay for services in the manner indicated in the Charges section on the Family Cost Share Agreement form. I understand that I must complete and sign a new Family Cost Share Agreement form.

I understand I can contact my service coordinator if I have questions about use of insurance or the payment arrangements on the Family Cost Share Agreement form.

Signature on file 7/15/2016Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Other IFSP Participants (printed name, credentials, signature, date):LP, MSW, CIP, 5/16/2016

Discipline: Service Coordinator

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other      

Name Credentials

Discipline: Educator/Special Educator Occupational Therapist Physical Therapist Speech-Language Pathologist Nurse Other           

The following individuals participated electronically or in writing (specify which):               

Physician Certification (required in order to bill insurance): I certify and approve that       services, as described in the IFSP, are medically necessary for this child.

Signature Credentials Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 23 DMH 888E 1044A

Child’s Name: Infant & ToddlerIFSP Date: DOB: Connection of Virginia Addendum(Refer to corresponding number in Section V of the IFSP for service details)# Service SERVICE PROVIDER (Name, agency, address, phone number) Current?1 Service

CoordinationSame N      N      N

2             N      N      N

3             N      N      N

4             N      N      N

5             N      N      N

6             N      N      N

7             N      N      N

8             N      N      N

I was given the opportunity to choose from among provider agencies who work in my local system area and who are in my payor network. I may request to change service providers at any time by contacting my service coordinator.

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

For Services # Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent Date

Infant &Toddler Connection of Virginia – IFSP – 7-15 ICI – E version Page 24 DMH 888E 1044A