Childs Name: Dahlia Prose 09-09-2008

Date of Birth: __________________

Local Program: __________________________________________
Demo Elementary x ID#:__________________________

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.

Meetings for the IFSP/IEP

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

3/3/11 Annual IFSP

March 2014 1
Childs Name: Date of Birth: __________________
Local Program: __________________________________________ x ID#:__________________________

I. Demographics and IFSP/IEP Team Membership

Child Information Family Information
Childs Name:Dahlia Prose Gender:F Name: Relationship:
Date of Birth: 09-09-2008 Age: 3 Address:
EIX#: City/State/Zip:
Referral Date: 03-04-2001 Phone (home): Phone (cell):
Referral Source:Parents Phone (work): Email:
Childs Address: 1221 North 24th Street Name: Relationship:
City/State/Zip: Byling, NE 64332 Address:
Phone #: City/State/Zip:
Primary Language: English Phone (home): Phone (cell):
School District of Residence: Demo School District Phone (work): Email:
County of Residence: Primary Language:
Interpreter Needed: Yes No
School District of Residence:
County of Residence:
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 Printed Name Attendance Signature
Parent/Guardian Patty Prose
Parent/Guardian Neal Prose
Special Education Teacher Melanie Dean
LEA Donald Patrick

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

Parent/Guardian Signature: __________________________

March 2014 2
Childs Name: Date of Birth: __________________
Local Program: __________________________________________ x ID#:__________________________

II. Child and Family Information

Summary of the Childs 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.

Neal has noticed that when Dahlia's favorite TV shows are on, that she watches intently and even tries to imitate what she sees (e.g. if Sponge
Bob stamps his foot or claps, Dahlia tries to do this)
Dahlia does not always respond to her name. Patty and Neal did have her hearing tested and the results indicated that Dahlia's hearing is within
normal limits Dahlia was diagnosed with autism by a specialist in Courtsville. The specialist recommended that Dahlia begin taking Melatonin to
help with sleeping. She also takes some other vitamins that were recommended by the doctor and Patty and Neal are noticing some positive
changes. Dahlia is up to date on her shots.
Dahlia follows simple directions about things she is familiar with: get your shoes, it's bath time, get your blanket, etc. If the family does not
understand her, she gets mad. Dahlia loves balls, she likes to put them into containers and then dump them out. Dahlia loves music and has
figured out how to turn on the radio and the TV. She especially likes to watch Sponge Bob and Yo-Gabba. Her family has noticed that she
sometimes imitates what she sees the characters doing, simple things like clapping and stomping her feet.

Summary of Family Information

Provide a summary from the Evaluation Report, if current, or update with current information.

Dahlia is not interested in being around other children. Parents would like her to play with them or her older sister.
They want to know more about the preschool at the school.
Dahlia does not say any words. She pulls Patty and Neal around if she wants something or screams. Parents would like to find some way for
Dahlia to let them know what she wants. Dahlia has meltdowns when the family goes places in the community. Parents would like to be able to go
somewhere altogether instead of one staying at home wtih Dahlia. Patty and Neal want to be able to talk to other parents and get more information
about autism. Patty and Neal want to use a Services Coordinator.
With parent consent, list assistance to the family in helping them access community, medical or other non-EI funded services.
If the parent does not want to address this item, document in the childs record.

March 2014 3
Childs Name: Date of Birth: __________________
Local Program: __________________________________________ x ID#:__________________________

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 at least 2 years 3 months of age?

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.

March 2014 4
Childs Name: Date of Birth: __________________
Local Program: __________________________________________ x ID#:__________________________

IV. Measurable Results/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.

Measurable Results/Outcome/Goal: 03/04/11

Date outcome/goal developed: ___________
09/18/11 Date outcome/goal completed: ___________
Measurable Results/Outcome/Goal Statement:
Dahlia will participate in the tickling game with her family by letting them know she wants another "turn". We will know she can do this when she lets
them know that she wants them to tickle her again using eye contact with a family member before or after looking attheir hand at least 3 times during
a game.
What is happening now? What is the childs current level of performance related to this outcome/goal?

Dahlia does not engage with her family unless tickling or music is occurring. Dahlia struggles to maintain eye contact and does not engage.

What teaching strategies are needed to reach the outcome/goal? Include specially designed instruction, supplementary aids and program personnel supports, home or
program modifications and training and materials needed by the family or team. Also include location and how all team members, including the family/caregivers/early childhood
educators, will work on this.
Dahlia's family will: Continue to use routine activities and any preferred toys that Dahlia likes as a way to motivate her to be with them. They will
reinforce this by doing what she wants them to do. Once the activity has started, stop and wait to see what Dahlia does. As much as possible,
use Dahlia's name and then wait to see if she responds. Pair this with the preferred activity if needed to keep her motivated.
The Primary Service Provider (ECSE) will: Engage in the favorite activities with the family and then observe and reflect with them about ways
that Dahlia may be indicating her turn or could learn to indicate her turn.

How will we as a team measure progress and collect data for this outcome/goal? Include what is going to be measured, how it will be measured, when it will
be measured and by whom. Describe when periodic reports on progress will be provided to the parent.

Monthly - by family and PSP - through observations and reports

The ECSE and the SLP will: make joint visits to discussion communication signals and strategies that can be used.
The ECSE and the SLP participate in weekly team meetings and receive coaching from the rest of the early intervention team..
After reviewing the outcome/goal and progress monitoring data, we, the team, have decided: (Check one)
We still need to work toward this outcome/goal. Lets continue with what we have been doing.
We still need to work toward this outcome/goal. Lets discuss new ways to get there.
Our situation has changed; we no longer need to work on this outcome/goal.
We are satisfied that we have finished this outcome/goal.
Other: ______________________________

Date of review: _____________

March 2014 5
Childs Name: Date of Birth: __________________
Local Program: __________________________________________ x ID#:__________________________

2
V. Early Intervention Services
3 5
Early Intervention Location Start Date Actual Service Frequency up Session Unit Cost Estimated
1 4 3
Service Delivered End Date to a Maximum Duration Total Cost
Date

ECSE Home 3/4/11 9/4/11 20 days/ 6 month period 60 min/day

Contact Person & Phone Number: Agency:
Primary Service Provider
Service Comments:

Speech Home 3/4/11 9/4/11 10 days/6 month period 60 min/day

Contact Person & Phone Number: Agency:

Speech Pathologist
Service Comments:

OT Home 3/4/11 9/4/11 1 day/6 month period 60 min/day

Contact Person & Phone Number: Agency:

Occupational Therapist
Service Comments:

Service Coordinator Home 3/4/11 8/31/11 1 day/month 30 min/day

Contact Person & Phone Number: Agency:

Services Coordinator
Service Comments:
1
All services will be on an individual basis unless otherwise indicated within the plan here and/or in the service page.
2
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.
3
If an Early Intervention service is projected to start later than 14 calendar days after the Start Date, a justification of the later date must be documented in the Service Comments section.
4
A unit is equal to 15 minutes.
5
Only completed by infant/toddler programs: This childs Infant/Toddler early intervention services may be funded through state, Medical Assistance or Infant/Toddler and Family Waiver funds.

March 2014 6
Childs Name: Date of Birth: __________________
Local Program: __________________________________________ x ID#:__________________________

VI. Participation in Regular Early Childhood Programs

Is the child currently attending a regular early childhood program? 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

P Where does the child receive the majority of hours of special education and related services?
R In the regular education program
E In some other location
S Home Setting
C
H Is the child receiving special education in a specialized setting? YES NO
O If Yes, how many hours per week does the child spend in a specialized setting? _______ hrs/wk
O Special Education Class
L Separate School
Residential facility
O Is the child receiving the majority special education and related services in the residence of the childs family or caregiver?
N Yes - Home
L No - Service Provider Location or some other location not in any other category
Y
EI Preschool Location of Intervention (LRE): ________________________________________________

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.

Currently Dahlia receives most services in the home setting. Dahlia will make visits to preschool this spring so that the team and family can make some decisions
about the kinds of supports she might need and also how she will react to being around other children

March 2014 7
Childs Name: Date of Birth: __________________
Local Program: __________________________________________ x ID#:__________________________

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:

Regression and recoupment data has not yet been collected for the 2010-2011 school year. At this time, Dahlia is ineligible for ESY
services but if this were to change, the IEP team would reconvene to make the appropriate changes to the IEP.

IX. Revisions to the IFSP/IEP

Date of Name and Role of Team Members involved IFSP/IEP Section(s) Amended Reasons for Revision
Revision(s) in the Revision

March 2014 8
Childs Name: Date of Birth: __________________
Local Program: __________________________________________ x ID#:__________________________

X. Transition Plan
A transition plan should be completed for children as identified in the Special Considerations section.
Transition Outcome/Goal:
Dahlia will make visits to preschool this spring so that the team and family can make some decisions about the kinds of supports
she might need and also how she will react to being around other children
Transition Document Dates:
Infant/Toddler: Preschool:
Date transition notification sent: 3/4/11 Date Intent to Register sent/given to Parent/Guardian:
Transition meeting held on: 3/4/11 Date Intent to Register received from Parent/Guardian:
Transition plan initially developed on: 3/4/11 Date Intent to Register sent/given to School District:
Transition plan updated on:

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; Date Actual
3. Steps to ensure a smooth transition, including sharing of information, and convening a meeting with the family, preschool EI Person Responsible To be Completion
program and/or community provider, or school district at least 90 days and up to 9 months prior to the childs 3rd birthday Completed Date
(infant/toddler) or by February 28 of the current program year for preschool EI.
Dahlia will make visits to preschool this spring so that the team and family can make some PSP, preschool teacher, principal, family
decisions about the kinds of supports she might need and also how she will react to being
around other children 3/4/11 - 9/4/11

Dahlia will make visits to the preschool room over the summer PSP, principal, family 3/4/11 - 9/4/11

The kindergarten teacher, school SLP,preschool teacher, and family will attend the Autism conference in April.
school personnel, principal, family, SC
3/4/11 - 9/4/11
Discuss transportation needs - both for spring and summer visits, as well as in the fall when Dahlia starts preschool.
PSP, family, SC, principal 3/4/11 - 9/4/11

March 2014 9