DELAWARE MULTIDISCIPLINARY ASSESSMENT/ INDIVIDUALIZED FAMILY SERVICE PLAN FOR THE FAMILY OF Date of Birth: ISIS Number: Plan Date: Review Date: MDA Only Section 1 Child’s Name: Date of Birth: Plan Date: DELAWARE MDA/IFSP Interim (See section 11) Date: Annual Date: Review Date: Sex: MCI/ISIS# Error! Reference source not found. Eligibility (Y N) date: Primary Language: Resident School District: Eligibility Determination Method: Dev. Delay Established Condition Clinical Judgment Parent(s) Child Resides with Guardian/Family Member/Other Child Resides with Foster Care Agency / Worker Name & Address Child Resides with Name: Street Address: City: Zip: Home Telephone: Work Telephone: Cell Telephone: Email Address: Doctor/Medical Home: Dr. Telephone # Fax #: Insurance Carrier/Insurance #/ Insured: Insurance Carrier/Insurance #/ Insured: Child’s present concerns and /or diagnosis: Service Coordinator: Telephone Number: Email: Section 2 Child’s Name: Date of Birth: Plan Date: IDENTIFYING NATURAL LEARNING ENVIRONMENTS FAMILY AND CHILD PREFERENCES, STRENGTHS AND RESOURCES What is soothing to your child? What is your child’s favorite activity (toy, game, playtime)? What is your child’s/family’s daily routine? Where/with whom does your child spend time? How often/how much time? What does your child do well? On most days, what goes well and what is difficult? Who is part of your family? Is extended family nearby and are they supportive? How do you and your family get to places you need to go? Do you have a child safety seat for a car? How do you presently meet your child’s needs for opportunities to interact with other children? What people and agencies do you find helpful? Additional Information: Section 3 Child’s Name: Date of Birth: Plan Date: FAMILY AND CHILD CONCERNS AND PRIORITIES CONCERNS AND PRIORITIES: Why are you interested in receiving help for your child? When were you first concerned? How do your child’s special needs affect the family? Describe activities/routines that your family is not currently involved in because of your child’s special needs, but that you are interested in doing now or in the near future? What is most important to you now and how can we help? I WANT TO KNOW MORE ABOUT: Meeting with other families to share information about a child like mine Planning for the future People who can help me at home or care for my child so I/we can have a break Resources for housing, clothing, jobs, food, telephone, child care Getting and paying for equipment, supplies, and assistive technology devices Locating a doctor or dentist Age appropriate developmental skills Other: I WOULD LIKE TIPS FOR: Effective discipline for my young child Using time-outs Toilet training Helping my child stay dry How to stop bed-wetting Handling hair pulling Stopping my child from biting others Stopping temper tantrums Helping my child become independent Parenting a “hyperactive” child How to help my child feel special Helping my fearful child Helping my child make changes How to stop sleeping problems How to prepare my child for a new baby Helping my children adjust to a new baby What to do when my children fight Teaching my children to share Helping step-brothers and step-sisters live together Parenting the brother/sisters of a child with a medical or handicapping condition. Section 4 Child’s Name: Date of Birth: Plan Date: DEVELOPMENTAL STRENGTHS AND CONCERNS FOR THE CHILD 1. COGNITIVE: These skills are the manner in which your child thinks and solves problems. At a young age, these skills include finding objects that have been removed from their view, recognizing themselves as the causes of events, matching simple shapes/colors, responding to one and one more, remembering details of a simple story and remembering where things belong in the house. Present Level of Functioning: Strengths / Resources Concerns / Needs / Priorities Family Input: Assessment Results Date: Assessment: Age at Evaluation: Corrected Age: Circle One: Developmental Delay DD Partial Delay PD No Delay ND Age Appropriate AA Clinical Impressions and Recommendations (Including behaviors, history, what impacted assessment, distractions, special adaptations.): Assessor: Section 4 Child’s Name: Date of Birth: Plan Date: DEVELOPMENTAL STRENGTHS AND CONCERNS FOR THE CHILD 2. ADAPTIVE: These self help skills are activities such as eating and dressing; the ability of children to focus their attention, and demonstrate their growing personal responsibility. This includes eating, toileting, dressing and attention skills. Is your child toilet trained? Does he/she require assistance in removing/putting on a jacket? How long can your child maintain attention to an activity? What activities does he/she tend to focus on the most? Present Level of Functioning: Strengths / Resources Concerns / Needs / Priorities Family Input: Assessment Results Date: Assessment: Age at Evaluation: Corrected Age: Circle One: Developmental Delay DD Partial Delay PD No Delay ND Age Appropriate AA Clinical Impressions and Recommendations (Including behaviors, history, what impacted assessment, distractions, special adaptations.): Assessor: Section 4 Child’s Name: Date of Birth: Plan Date: DEVELOPMENTAL STRENGTHS AND CONCERNS FOR THE CHILD 3. SOCIAL / EMOTIONAL: Social/Emotional skills are the ways the child interacts with adults and peers, how they express their feelings. This includes familiar adults, other children and strangers. Does your child follow routine directions? Does he/she share toys with other children? Does he/she prefer to play alone or with others? Present Level of Functioning: Strengths / Resources Concerns / Needs / Priorities Family Input: Assessment Results Date: Assessment: Age at Evaluation: Corrected Age: Circle One: Developmental Delay DD Partial Delay PD No Delay ND Age Appropriate AA Clinical Impressions and Recommendations (Including behaviors, history, what impacted assessment, distractions, special adaptations.): Assessor: Section 4 Child’s Name: Date of Birth: Plan Date: DEVELOPMENTAL STRENGTHS AND CONCERNS FOR THE CHILD 4. PHYSICAL: These skills include both large and small muscle movements. Gross motor development is the ability to move from one position to another, such as crawling. Fine motor skills are seen in the child’s ability to manipulate toys and other objects with their hands. How well does your child walk, run and jump? How does he/she do on the stairs? Can he/she reach out and hold onto objects? Does he/she throw a ball, stack blocks, and use scissors to cut, ride a riding toy? What does he/she do with a crayon? Does he/she appear clumsy or have difficulty working with very small items? Present Level of Functioning: Strengths / Resources Concerns / Needs / Priorities Family Input: Assessment Results Date: Age at Evaluation: Corrected Age: Fine Motor Assessment: Developmental Delay DD Partial Delay PD No Delay ND Age Appropriate AA Gross Motor Assessment: Developmental Delay DD Partial Delay PD No Delay ND Age Appropriate AA Fine Motor: Gross Motor: Fine Motor: Gross Motor: Clinical Impressions and Recommendations (Including behaviors, history, what impacted assessment, distractions, special adaptations.) : Assessor: Section 4 Child’s Name: Date of Birth: Plan Date: DEVELOPMENTAL STRENGTHS AND CONCERNS FOR THE CHILD 5. COMMUNICATION: These skills include the child’s ability to understand others (receptive communication) and to express themselves (expressive communication) with words and/or gestures. This includes use of sounds, words, or gestures to let you know his/her needs, as well as how well he/she understands what is being said to him/her. How does your child respond to what is said? Does your child point to pictures or name pictures? What sound, words, or gestures does your child use? Is he/she putting words together? Present Level of Functioning: Strengths / Resources Concerns / Needs / Priorities Family Input: Assessment Results Date: Age at Evaluation: Corrected Age: Receptive Communication Assessment: Developmental Delay DD Partial Delay PD No Delay ND Age Appropriate AA Expressive Communication Assessment: Developmental Delay DD Partial Delay PD No Delay ND Age Appropriate AA Receptive Communication: Expressive Communication: Receptive Communication: Expressive Communication: Clinical Impressions and Recommendations (Including behaviors, history, what impacted assessment, distractions, special adaptations.): Assessor: Section 5 Child’s Name: Date of Birth: Plan Date: HEALTH ASSESSMENT Present Levels of Functioning Strengths / Resources Concerns / Needs / Priorities Primary Care Physician: Vision: Hearing: (newborn screen, # ear infections, tx?) Nutrition: (eating patterns, fluid intake, bottle/breast) Growth and Development: (birth weight, length, dev milestones) Significant Medical Findings: (diagnoses) Health History: (birth history, immunizations, accidents, illnesses, hospitalizations, last physical) Other Specialty Medical Follow up: Section 6 Child’s Name: Date of Birth: Plan Date: OUTCOME # Outcomes must be written in language that is easily understood by all IFSP team members. Outcome Statement: What we would like our child to be able to do. Things we will do to make this happen: Completed During the IFSP Review How are we doing? Review Date: After reviewing the outcome, we as a family, have decided: (Check One) We still need to work toward this outcome. Let’s continue with what we have been doing. We still need to work toward this outcome. Let’s discuss new ways to get there. Our situation has changed; we no longer need to work on this outcome. We are satisfied that we have finished this outcome. Other: Comments: How are we doing? Review Date: After reviewing the outcome, we as a family, have decided: (Check One) We still need to work toward this outcome. Let’s continue with what we have been doing. We still need to work toward this outcome. Let’s discuss new ways to get there. Our situation has changed; we no longer need to work on this outcome. We are satisfied that we have finished this outcome. Other: Comments: Section 7 Child’s Name: Date of Birth: Plan Date: TRANSITION OUTCOMES Outcome Statement: What we would like our child to be able to do: To smoothly transition to appropriate programming when exiting Child Development Watch. Things we will do to make this happen: Service Coordinator to: Introduce transition to family at first face- to-face contact. These steps must begin by age 2. Discuss possible options with family such as Stay and Plays, private preschools, Head Starts, and school district public preschool services. Discuss differences between CDW early intervention and school district special education. Provide family with brochures and handouts regarding transition process. Inform family of Parent Information Center and provide contact information. Obtain written family consent to release information to appropriate agencies. Make referrals to agencies. (9 months before child exits CDW) Ask family to identify individuals they wish to invite to the Transition Conference. Arrange Conference/send notices. (around 6 months and at least 90 days before child exits CDW) Attend Transition Conference along with parent(s) and receiving agency. (See Transition Plan) How are we doing? Review Date: Completed During the IFSP Review After reviewing the outcome, we as a family, have decided: (Check One) We still need to work toward this outcome. Let’s continue with what we have been doing. We still need to work toward this outcome. Let’s discuss new ways to get there. Our situation has changed; we no longer need to work on this outcome. We are satisfied that we have finished this outcome. Other: Comments: After reviewing the outcome, we as a family, have decided: (Check One) Review Date: We still need to work toward this outcome. Let’s continue with what we have been doing. We still need to work toward this outcome. Let’s discuss new ways to get there. Our situation has changed; we no longer need to work on this outcome. We are satisfied that we have finished this outcome. Other: Comments: Section 8 Child’s Name: Date of Birth: Plan Date: NATURAL ENVIRONMENTS (NE): Early Intervention services must be provided in NE (settings that are natural/typical for the child’s age peers who have no disabilities) to the maximum extent appropriate, and can only be provided in settings other than NE when outcomes cannot be achieved satisfactorily in NE. The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) requires justification to support the IFSP team decision that outcome/strategies cannot be achieved satisfactorily in NE. Outcome # 1) Why outcomes/strategies cannot be achieved in the NE? 2) Plan/timeline to move service(s) into the NE. All services provided in Natural Environments Section 9 Child’s Name: Date of Birth: Plan Date: ALL SERVICES Provider Contact Name Phone Number Service Type/ Profession Refr. Date Start Date End Date Frequency/ Intensity Method/ Location Disposition/ Gap Reason Payor (1st, 2nd, 3rd) Section 10: Child’s Name: DOB: School District: TRANSITION PLAN PLAN FOR TRANSITION FROM THE BIRTH TO THREE SYSTEM TO PRESCHOOL SPECIAL EDUCATION OR OTHER APPROPRIATE SERVICES Purpose for this plan: Conference Date: Anticipated Transition Date: Conference notes: Next Steps Person Responsible Date to be Completed Completed Fax Transition Plan to Service Providers. Family requests that CDW Service Coordinator be invited to IEP meeting. PERSONS INVOLVED IN TRANSITION PLANNING (Persons required to attend are family member(s) and the service coordinator. If the child has been referred to a school district for determination of eligibility for pre-school special education, then a representative of the child’s school district must also attend.) Place a check the small box to indicate attendance at the conference. Name Title Phone Name Title Phone Service School District 12/04/08 Parent: Date: Coordinator: Date: Representative: Date: Use Triplicate Form Section 11 Child’s Name: Date of Birth: Plan Date: ADDITIONAL COMMENTS This section is provided for any additional comments that the parents, service coordinator and/or other team members feel would be helpful. Each comment should be dated and signed. Interim IFSP due to: Unable to complete MDA due to child’s condition Eligible child has immediate service needs prior to the MDA Explanation: Anticipated MDA date: Additional Comments: Mailed IFSP to Family: (Date: ) Mailed IFSP to Family: (Date: ) Section 12 Child’s Name: Date of Birth: Plan Date: SIGNATURE PAGE I had the opportunity to participate in the development of this IFSP. I understand the plan, and I give permission to Child Development Watch to carry out the plan with me. I have received and read a copy of Family’s Rights. I have had the opportunity to receive and review the Division of Public Health’s Notice of Privacy Practices. IFSP Meeting Notice sent or Waiver signed Signature of Parent(s) / Legal Guardian(s)/ Educational Surrogate Plan Date The following individuals participated in the development of the IFSP. Each person understands and agrees to carry out the plan as it applies to their role in the provision of services. Please include name, role and relationship to the child. Initial Plan Date: Signature Role / Relationship Signature Role / Relationship I had the opportunity to participate in the development of this IFSP. I understand the plan, and I give permission to Child Development Watch to carry out the plan with me. I have received and read a copy of Family’s Rights. I have had the opportunity to receive and review the Division of Public Health’s Notice of Privacy Practices. IFSP Meeting Notice sent or Waiver signed Plan Date: Signature Role / Relationship Signature Role / Relationship