Office of Child Development and Early Learning

Individualized Family Service Plan (IFSP)

Individualized Education Program (IEP)

The IFSP and IEP are plans that identify services and supports so that family members and early education
programs are actively engaged in promoting the childs learning and development.

The IFSP/IEP team determines the skills/abilities and appropriate supports and services either in the
natural environment or the least restrictive environment to accomplish the established goals and outcomes.

These decisions are not made by matching the childs areas of delay with a particular Early Intervention
discipline. Rather, supports and strategies are individualized and build on the strengths and skills the child
demonstrates in all areas of development.

The IFSP and IEP are plans that consider: the strengths of the child; concerns of the parent/guardian; most
recent evaluation results; academic, developmental and functional needs of the child; communication
needs of the child; and will incorporate revisions to the plan to address lack of progress.

Date meeting(s) held

Purpose Of Meeting(s)
(Ex.: Initial IFSP/IEP, Annual, Revisions)

6/08

Initial IFSP

I. Demographics and IFSP/IEP Team Membership

Child Information

Family Information

Childs Name: XX B. XX Gender: x M F

Date of Birth: 03/17/2012 Age: 2:7
MA Recipient #:
Have parents approved billing of Medical Assistance? Yes No
Private insurance YES NO
Referral Date:
Referral Source: Dr. Marcus Welby (otolaryngologist)
Childs Address:
City/State/Zip: XX, PA 17815
Phone #:
Primary Language: English

Name: Todd XX Relationship: Father

Address:
City/State/Zip: XX, PA 17815
Phone (home): Phone (cell):
Phone (work): Email:
Name: XX XX Relationship: Mother
Address:
City/State/Zip: XX, PA 17815
Phone (home): Phone (cell):
Phone (work): Email:
Primary Language: English
Interpreter Needed: Yes x No
School District of Residence: XX Area School District
County of Residence: Columbia

School District of Residence: XX Area School District

County of Residence: Columbia
Other:

IFSP/IEP Team Membership:

Members shall include: parent and others as requested by the parent (if feasible); the County Designee/Service Coordinator (infant/toddler) or Local Education Agency
Representative (preschool) must be present for the meeting; a person directly involved with evaluation and assessment results who can interpret instructional implications; a person
who will be providing services, as appropriate (infant/toddler); a regular education and a special education teacher (preschool).

Role
Parent/Guardian
Parent/Guardian
Grandparent
SLP

Printed Name
Todd XX
XX XX
XX XX
Stephanie Fowler

Attendance Signature

The following individuals provided information to the IFSP/IEP team but did not attend or were excused from the meeting.
Role
Printed Name

Parent(s) received copy of Procedural Safeguards/Parents Rights Agreement Yes No

6/08

II. Child and Family Information

Summary of the ChiXXs Present Performance
Provide a summary from the Evaluation Report, if current, or update with current information. This summary describes the childs strengths (including strengths that exist in areas of
concern) and the childs needs. Include developmental, academic achievement (preschool), and functional performance. Describe how the childs developmental delay or disability
affects the childs involvement in everyday routines and appropriate activities. Describe instructional strategies that have been successful and how they can be incorporated into
the childs educational program and curriculum that will support the child. Describe the childs favorite activities and materials, and factors that motivate the child to participate and
learn.
XX displays many strengths in the areas of fine and gross motor skills. His strengths in gross motor skills include the ability to run well inside and out, standing on his

tip toes when reaching for objects, and jumping up and down and showing good control/range of motion of feet while dancing. He is also capable of walking up and
down stairs with his hand being held, throwing a ball overhand and kicking a ball forward. His strengths of fine motor development include scribbling with crayons,
stacking blocks, grabbing small objects with thumb and finger, grabbing large objects with whole hand, and using utensils while eating. In the area of cognitive
development, XX has many strengths. He is capable of finding objects buried in the sand, pretending to drink from an empty cup, racing Matchbox cars, and dancing
when music is playing. XXs needs in this area include pointing to desired objects, following directions, completing puzzles, responding to his name, pointing to
pictures on request, turning pages of books one at a time and identifying body parts. In the area of communication development, XXs strengths include the ability to
say dada, the use of babbling and unrecognizable words, and the ability to maintain attention to activities he enjoys. XXs needs include controlling frustration, using
the words mama and dada specifically, using recognizable words, naming objects and pictures, imitating words and sounds, following directions, responding to his
name and pointing to indicate what he wants. Another need is to respond to words like no and stop. In the area of social and emotional development, XX exhibits
his strengths through showing a preference for toys and activities, showing affection by giving hugs and kisses and displays a recognition for family members. XX
also shows a variety of emotions, plays next to other children and engages in solitary play. His needs include finding an appropriate way to express his frustration
that is not harmful to himself or others, learning to share toys with his brother, and getting more involved with other children at daycare. In the area of adaptive
development, XX shows his strengths through feeding himself from a spoon, drinking from a sippy cup, finger feeding, putting on his own pants (as long as they do
not have buttons or zippers), undressing himself, wiping his nose, and eating a variety of textures. He also obtains objects within reach, brushes his teeth with some
help, sleeps about 10 hours a night and takes a 1-2 hour nap in the afternoon. One of XXs needs is to increase ability for following instructions, instead of having him
be physically taken to each activity, as well as asking for help instead of trying to get everything down from the cabinets himself. One of the familys needs is to be
able to control his tantrums in order to go out as a family. They would like XX to be able to express what he wants so that they no longer have to continuously guess.
XXs mom would like to be able to interact in joint activities such as puzzles, reading books and talking. The familys needs include finding a way to give equal
attention to all members of the family. XX suffers from frequent ear infections and has had two sets of tubes put in his ears. XXs interests include dancing to music,
going for walks in the stroller, and looking at things in the store. He enjoys looking at picture books with animals, playing with cars and playing in the sand table.

Summary of Family Information

Provide a summary from the Evaluation Report, if current, or update with current information.
XX is the son of XX and XX XX. He has a 5 year old brother, XX, and a sister, XX, who is 11 months old. XXs older brother received early intervention services
through a birth-to-three program for speech and language. XX currently receives services through the XX Area School District. XX XX works at the XX in XX and XX
works variable shifts at XX. XX, XXs maternal grandmother, also lives with the family. She watches the children occasionally, but has just had back surgery so
cannot lift the children or play with them in any activities that require great movement.

With parent consent, list assistance to the family in helping them access community, medical or other non-EI funded services.
6/08
If the parent does not want to address this item, document in the childs record.
3

III. Special Considerations

Following are special factors the IFSP/ IEP team must consider before developing the IFSP/ IEP. Each question must be answered. If YES is checked, the IFSP/IEP must address
the childs needs related to any identified special factor.

1. Is the child blind or visually impaired?

NO
YES - As developmentally appropriate for the infant, toddler, and preschooler, the IFSP/IEP team should evaluate the childs early literacy needs,
including reading and writing media. The IFSP/IEP must consider the current and future needs of the child related to the use of Braille if the team
decides that this is appropriate for the child.
2. Is the child deaf or hard of hearing?
NO
YES - Team must consider the infants, toddlers or preschooler's language and communication needs, opportunities for direct communication with
peers and professionals in the child's language and communication mode, academic level, and full range of needs including opportunities for direct
instruction in the child's language and communication mode in the development of the IFSP/IEP.
3. Does the child exhibit behaviors that impede the childs learning or that of others?
NO
YES - Team must base the use of positive behavior interventions and supports, and other strategies to address that behavior on a functional
behavior assessment.
4. Does the child have limited English proficiency (e.g., the childs home language is not English)?
NO
YES - Team must consider the family and childs language needs as those needs relate to the development and implementation of the IFSP/IEP.
5. Does the child have communication needs?
NO
YES - Team must consider the communication needs of the child in the development of the IFSP/IEP.
6. Does the child need assistive technology devices and/or services?
NO
YES - Team must consider the infants, toddlers or preschooler's assistive technology needs in the development of the IFSP/IEP.
7. Is it anticipated that the infant/toddler or preschooler will be transitioning from the Early Intervention program because of a transition in the life of
the family and child?
NO
YES - The IFSP/IEP should address the childs transition to future community programs and the needs of the family related to the transition.
8. Is this an IFSP for a toddler who is close to his/her second birthday?
NO
YES - The IFSP must include a transition plan that addresses the child and familys needs related to the transition to the Part B program if eligible or
to other community programs.
9. Is this a preschooler within 1 year of transition to a program for Kindergarten age children?
NO
YES - The IEP must include a transition plan that addresses the transition process.

6/08

IV. Outcome/Goal #

Activity/behavior/skill in everyday life, identified by the family and the IFSP/IEP team, that they would like to see happen. Includes information on the routine/activity of the family,
community, or early childhood setting where the behavior/skills will be incorporated. Should address the childs needs identified in the evaluation and the priorities of the family.
Be
functional and measurable to provide a framework for ongoing progress monitoring. Goal should be developed in accord with the PA Early Learning Standards and enable the
child to be involved in and make progress in the general curriculum.

Outcome/Goal: Date outcome/goal developed: Date outcome/goal completed:

Outcome Goal #1- XX will learn to point to preferred items to indicate to his caregivers his wants and needs and will learn strategies to show his frustration in a way
that does not harm himself or others.
What is happening now? What is the childs current level of performance related to this outcome/goal?

Outcome Goal #1- XX currently tries to get everything himself, often times putting himself in a dangerous situation. He does not point to indicate preferred items, which causes great
frustration to XX and his parents when trying to constantly guess what he wants. XX currently throws tantrums when he gets frustrated by stomping his feet and crying. When he gets
very frustrated he throws himself down and bangs his head on the floor. This causes his parents and family members great distress for the fear he will harm himself. By working toward
this goal, it will help ease the familys frustration when trying to interact with XX and reduce the fear the family is currently experiencing that he will hurt himself when he gets upset.

What teaching strategies are needed to reach the outcome/goal?

Outcome Goal #1- A PECS system will be proposed to the family to be put in place. The family will be provided with a laminated piece of paper with Velcro strips on it. The family will be
introduced with how the PECS system works and how it may be beneficial to XX. If he has a picture representation, it will be easier for XX to express what he wants, instead of the
family having to guess. The addition of a need help picture will promote pointing to the pictures instead of XX climbing to get things himself. The family will be provided with a packet
explaining the PECS system and that it can be used as a vehicle into expressive language. They will also be provided with websites they can look at for tips and resources that support
the use of the PECS system. The family will be integrated by helping decide the picture representations they feel will be most used and most important for XX and the family. Each
caregiver (mother, father, and grandmother) will be trained in using PECS. The family will be trained with strategies to elicit communication. For example, they will be taught things like to
give XX something he wants with the lid on too tight to promote him to ask for help and other such techniques. For the second half of the goal, the family will be provided with a
pamphlet of strategies to work on with XX for controlling frustration. These will include things like stress balls, breathing exercises, mental breaks, etc. The family and the SLP will work
together to see what works best for XX in helping to control the frustration. XX will not continue to bang his head on the floor and the family will intervene when this happens. The family
will also be provided with websites and help groups with other parents of children that exhibit similar behaviors. This will help them interact and see what strategies helped other families.

6/08



How will we as a team measure progress and collect data for this outcome/goal? Include what is going to be

After reviewing the outcome/goal and

progress monitoring data, we, the team, have
decided:(Check one) Date of review:

measured, how it will be measure, when it will be measured and by whom. Describe when periodic reports on progress will be
We still need to work toward this outcome/goal.
provided to the parent.
Lets continue with what we have been doing.

We still need to work toward this outcome/goal.
Outcome Goal #1- The family will keep data of how XX did throughout the day with pointing and using the PECS system to
Lets discuss new ways to get there.
express his wants and needs. This will be done through a family log/journal. At the end of every day, the caregivers who interacted
Our situation has changed; we no longer need
and worked with XX that day will keep a family journal/log. This will include an overall opinion of how the day went, any specific
to work on this outcome/goal.
instances in which XX was very successful, or any situations in which the system did not work as intended. This will be looked
We are satisfied that we have finished this
over each week at the beginning of the session with the SLP and the caregivers can give an overall impression of how things are
outcome/goal.
going and what they feel needs to be modified. This will also be a running log for the family to see the progress XX is making.
Other:

The family will use this same log and have a separate entry for XXs overall temperament throughout the day. This section will
include any tantrums they saw, what strategies were used to combat it and whether they were successful or not. Triggers to the
tantrum may also be included in order to see what specific things are causing increased frustration in XX. Again, this journal will be
gone over at the start of the session and talked through with the caregivers to see if any changes are suggested.

6/08

V. Early Intervention Services

Early Intervention
Service

Location (1)

Start
Date (2)

Actual
Anticipated
Delivered
Service
Date
End Date

Contact Person:

Agency, Address, & Phone Number

Contact Person:

Agency, Address, & Phone Number

Contact Person:

Agency, Address, & Phone Number

Contact Person:

Agency, Address, & Phone Number

Contact Person:

Agency, Address, & Phone Number

Contact Person:

Agency, Address, & Phone Number

Actual
Service
End
Date

Frequency
up to a
maximum

Session
Duration

Funding
Source
(3)

Unit
Cost
(3)

Estimated
Total Cost
(3)

County designee approving EI services (3):

(1) If IFSP/IEP services/supports are not being provided in a natural environment or an inclusive environment, complete the sections titled Participation with
Typically Developing Children.
(2) If an Early Intervention service is projected to start later than 14 calendar days after the IFSP/IEP is completed, a justification of the later date must be
attached.
(3) Only completed by infant/toddler programs
6/08

VI. Participation in Regular Early Childhood Programs

Is the child currently attending a regular early childhood program? x YES NO

(Early care and education programs include, but are not limited to: Early Head Start, Head Start, preschools, or child care; including reverse mainstreaming. Attendance at an
early childhood program need not be funded by Early Intervention funds.)

If yes, how many hours per week does the child spend in the regular early childhood program? hrs/wk
(Record the total time in hours that the child typically spends in the early childhood program each week, even if Early Intervention services are provided in a different location.)

For
Preschool
Only

Using form titled Educational Environment Worksheet, please determine the percentage of time this child is educated within a regular early
childhood program, and check the corresponding box below:
The child attends a regular early childhood program (checked yes for the first question above):
The percentage of time inside a regular early childhood program for this student is 80% or more of the week.
The percentage of time inside a regular early childhood program for this student is no more than 79% of the week and no less than 40% of
the week.
The percentage of time inside a regular early childhood program for this student is less than 40% of the week.

The child DOES NOT attend an Early Childhood Program but DOES attend a Special Education Program/Class (checked no for the first question above)
Separate Class: Child attends a special education program in a class with less than 50% nondisabled children
Separate School: Child receives education programs in public or private day school designed specifically for children with disabilities
Residential: Child receives special education and related services in a residential facility
Service Provider Location: Child receives all special education and related services from a service provider (clinicians,
office, hospital facility etc)
Home: Child receives special education and related services in the principle residence of the childs family or caregiver.

EI Preschool
Location of
(List location as described in Preschool PennData EI Reference Sheet)
Intervention

VII. Participation with Typically Developing Children

For infants and toddlers: Explain why and to what extent the eligible child does not receive Early Intervention services in their natural environment.
For preschool age children: Explain why and to what extent the eligible child will not participate with typically developing peers in appropriate preschool activities.
For eligible infants, toddlers and preschool children: Include in what environment the child will receive Early Intervention services, the reason for this
placement, and ways to maximize the opportunities for the child to participate with typically developing peers in natural/inclusive environments.

VIII. Early Intervention Services during Scheduled Breaks - PRESCHOOL ONLY

All services are based upon the preschool early intervention calendar. If the IEP team determines that this child is eligible for preschool special education services
during scheduled breaks based on the educational needs of child, specify the services below.
The IEP team has considered and discussed services during scheduled breaks and determined that:
This child does NOT need services during scheduled breaks based on:
This child needs services during scheduled breaks based on:

6/08

IX. Revisions to the IFSP/IEP

Date of
Revision(s)

6/08

Name and Role of Team Members involved

in the Revision

IFSP/IEP Section(s) Amended and Reason for Revision

X. Transition Plan

A transition plan should be completed for children as identified in the Special Considerations section.

Transition Outcome/Goal:
At three years of age, XX will be enrolled in a preschool setting.
What is happening now? What information and child and family considerations should be shared with the team in order to better prepare for
transition?

Activities/Services Designed to Ensure a Smooth Transition In Early Intervention

The plan should include at least the following:

1. Discussions with the parent regarding future support and other matters related to transition;
2. Steps to prepare the toddler/young child for changes based on developmental needs, including activities to help the adjustment to and
participation in new settings;
Person
3. Steps to ensure a smooth transition, including sharing of information, and convening a meeting with the family, preschool EI program and/or
rd
community provider, or school district at least 90 days and up to 9 months prior to the childs 3 birthday(infant/toddler) or by February 28 of the Responsible
current program year for preschool EI.

Date To be
Completed

Actual
Completion
Date

Gather child progress measurement information, review with family, and complete Child Outcome Summary Form.

Transition Plan Dates

Transition plan initially developed on:
Transition plan updated on:

Team members signatures:

Transition meeting held on:

Participants at Required Transition Meeting:
(Write in participants name and initial to indicate
attendance at required transition meeting.)
Parent/Guardian
County EI Rep
Preschool EI Rep
School Dist. Rep

To be completed during transition meeting along

with any other required documentation.
6/08

Comm. Prog. Rep*

IFSP/IEP Provider*
Other*
Other*
Other*
Other*
*(as needed)

1
0