Individualized Family Service Plan (IFSP) Individualized Education Program (IEP)

Dahlia Prose
Childs Name: Date of Birth: __________________

9/9/2008
Local Program: __________________________________________ 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)
9/17/17
Initial IFSP
March 2014 1
Childs Name: Dahlia Prose Date of Birth: __________________
9/9/2008
I. Demographics and IFSP/IEP Team Membership

Child Information Family Information
Childs Name: Dahlia Prose Gender:Female Name: Patty Prose Relationship: Mother
Date of Birth: 9/9/2008 Age: 3 Address: Same as Student
EIX#: City/State/Zip:
Referral Date: Phone (home): Phone (cell):
Referral Source: Phone (work): Email:
Childs Address: 1221 North 24th Street Name: Neal Prose Relationship: Father
City/State/Zip: Byling, NE 64332 Address: Same as student
Phone #: City/State/Zip:
Primary Language: Phone (home): Phone (cell):
School District of Residence: DEMO District Phone (work): Email:
County of Residence: Primary Language: English
Interpreter Needed: Yes No
School District of Residence: Demo district
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
Case Manager Danelle Locke
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
9/9/2008
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. She likes things to be
a certain way. Dahlia recognizes her favorite cereal when she sees the box on the cupboard and will try to reach for it, fusses if she is not able to touch it. Dahlia pulls Patty, Neal and her older sister by the hand or pushes them from behind to
what she wants. She also puts her hand on their hand until they get what she wants. She lets them know if she doesnt want something by pushing things away or screaming. The family has heard some vocalizations, like ah, uh, yaya, eeh, but
they are not sure if the sounds are intentional or not. Dahlia likes to be tickled, especially by Neal and will anticipate his hands by curling up into a ball and smiling and taking quick breaths. She will put her hand on her Dad's hand or looks at his
hand if she wants him to continue but has not yet started the tickling game or looked at the adult's face on her own. When the family goes to Walmart, Dahlia starts to get agitated, trying to get away and fussing. Sometimes the family can distract
her if she has her blanket and can chew on it, but if she gets really upset, she will scream or throw things. Once they leave Walmart and get into the car, they can get Dahlia to calm if she has her blanket and if Patty or Neal squeeze her tightly. It
is very difficult to get Dahlia to make eye contact, and she will usually isolate herself from the family unless there is music or the tickling going on. Dahlia used to wake up several times a night, but now since they have started the Melatonin, she
has done much better. Dahlia likes to eat but only certain things: chicken nuggets, French fries, corn dogs and ham. She also likes yogurt but only one brand. She can eat with utensils but tends to use fingers more. If Dahlia gets ahold of a pen,
she will scribble on anything. She likes to stack her big wooden blocks because her older sister will knock them down. Dahlia walks and runs on her toes sometimes. Sometimes she will dance if her family is dancing and her favoritemusic is on.
She loves to be outside in the sandbox and will get in/out over the ledge on her own. She also loves to swing and has figured out how to get in/out of the swing by herself too
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 with Dahlia. Patty and Neal have been talking to another family in their community and
have found this to be helpful. Dahlia has been sleeping better which seems to make it easier to get her to take them to what she wants without the
meltdowns. Dahlia has been healthy. Patty and Neal have been in contact with a doctor in Courtsville who has provided alot of information about autism.
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.
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.
March 2014 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 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
Dahlia Prose
9/9/2008
IV. Measurable Results/Outcome/Goal #____

1
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: Date outcome/goal developed: ___________ 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 at their 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 pulls people to what she wants. She will also put her hand on their hand.
If the family is doing something Dahlia likes, such as listening to music, she will come over to that area.
Dahlia loves the tickling game and anticipates that Neal will tickle her again by curling up ina ball and watching his hand closely
Text designed instruction, supplementary aids and program personnel supports, home or
What teaching strategies are needed to reach the outcome/goal? Include specially
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.
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.
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. Figure out, with the family,
how to get Dahlia to make eye contact, and then begin moving her gaze back/forth between the person and what she wants them to do. Discuss other activities and play routines that could be used for
Dahlia taking turns, and include herolder sister, and then determine how to use interventions across other activities and routines. ECSE visits will be more frequent in the beginning, as often as needed to
allow for the kinds of supports the family needs to learn how to support this outcome (e.g. modeling, feedback, etc.).
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.
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. The progress will be reviewed monthly by the Family and the PSP through observation.
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: _____________

9/4/2011
March 2014 5
9/9/2008

2
Dahlia will participate in bath time and meal time by letting her family know what she wants. We will know she can do this when she uses at least one other way of communicating (other than pulling and
putting her hand on the family's hand) during these routines daily.
Dahlia pulls her family to what she wants and puts her hand on theirs. Dahlia is making some sounds. Dahlia hands her cup to Patty or Neal when she wants more and likes to drink water in the
bath tub. Dahlia loves bath time and runs up stairs when someone says "its time to take a bath". Patty and Neal have been reading about sign language and are interested in trying some simple
ones.
What teaching strategies are needed to reach the outcome/goal? Include specially designed instruction, supplementary aids and program personnel supports, home or
Wait for Dahlia to let them know she wants more to drink or that she wants to get into the tub. Try forgetting to put Dahlia's favorite cup into the tub to see how she responds, or say its bath time but then
wait before going to the bathroom to see what Dahlia does. Put small amounts of water into Dahlia's drinking cup so that she has to come back for more. Consider, with the family, signing and other
communication strategies which might be useful for the routines and activities that are the most motivating for Dahlia. Model and/or try out how to teach Dahlia these things. Explore the possibility of
using picture exchange or simple switches as a means of communication. ECSE visits will be more frequent in the beginning, as often as needed to allow for the kinds of supports the family needs to
learn how to support this outcome (e.g. modeling, feedback, etc.).
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. The goal is going to be
measured monthly by the Family and PSP through observation and report
Other: ______________________________
March 2014 5
9/9/2008
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
20 day/ 6 month 60 mins/ a day
ECSE Home 3/4/2011 9/4/2011
period
Contact Person & Phone Number: Agency:

School District
Service Comments:
1 day/ 6 month
Speech Language Therapy Home 3/4/2011 9/4/2011 60 mins/ a day
period

Speech Pathologist School District
Service Comments:
Service Coordinator Home 3/4/2011 9/4/2011 1 day/ month 30 mins/ a day

Early Development Network
Service Coordinator
Service Comments:
1 day/ 6 month
9/4/2011 60 mins/ a day
Occupational Therapy Home 3/4/2011 period

Occupational therapist School District
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
9/9/2008
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
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.
Dahlia does receive early interventions in her natural enviornment.
March 2014 7
Dahlia Prose
9/9/2008

3
Patty and Neal will have strategies they can use to help Dahlia cope with being at the store for longer than 10 minutes. We will know this goal has been met when the family goes to the store altogether and is able
to finish their shopping at least 3 times in a 2 week period.
Right now, Patty or Neal usually go to the store separately so that Dahlia does not have to deal with it.
Dahlia lasts about 10 minutes. On a few occasions, Dahlia was distracted by having her cup along. Having her blanket helps calm her but only if she is out of the store.
Squeezing helps her calm down.
Text designed instruction, supplementary aids and program personnel supports, home or
What teaching strategies are needed to reach the outcome/goal? Include specially
The family will: Try going to a different store with Dahlia to see if this makes any difference. Talk with the other family they know in town about things they have used with their child
Talk with the OT on the team to see about ideas for how to use the squeezing in ways that might help Dahlia deal with the store
experience. Share information with the family about visuals (pictures, stories, etc.) that can be used to help Dahlia deal with difficult experiences.Since Dahlia recognizes her favorite cereal box, discuss
ways to incorporate this into the trip to the store to help prime Dahlia for what will happen. If the family agrees, help develop something for the store. Meet the family at Walmart or another store to try out
agreed upon strategies including the possibility of starting with short trips first, e.g. only buying 1 or 2 things as well as ways to immediately reinforce any time, no matter how short, that Dahlia is able to
be in the store without having a meltdown. The ECSE participates in weekly team meetings and receives coaching from the rest of the early intervention team.
The ECSE participates in weekly team meetings and receives coaching from the rest of the early intervention team. The goal
will be measured monthly by Family and PSP through observation and report.
Other: ______________________________

9/4/2011
March 2014 5
9/9/2008

4
Patty and Neal will have information about how to connect with other families and, what the preschool is like to help them make
decisions about present and future experiences and opportunities for Dahlia and their family by May of 2011.
Patty and Neal have already connected with one family in their community who has a child with autism.
Patty and Neal have talked with the school elementary principalabout the preschool in town.
Patty and Neal have learned from previous experiences with Dahlia that she needs to have more than one time to go to a new
place to get used to it.
The family will:
schedule a time to visit the preschool.Think about questions they have for other families and what their priorities are for making these connections. Attend the upcoming ASD conference.
The Primary Service Provider (ECSE) and the Services Coordinator will:
meet the family at the school and help them ask questions of the teacher and building principal. Talk with the school about scheduling some times when Dahlia and the family can both visit, both this
spring and also over the summer.
make a referral to the ASD team. connect the family with PTI of Nebraska. invite the family to come to a Planning Region Team meeting.
The Services Coordinator will:
make contact with the family at least every month - one month in the home, the next a phone contact, to document progress and make sure that all team members are connected with one another.
Progress will be monitored every two months by the family service coordinator, and PSP.
Other: ______________________________

9/4/2011
March 2014 5
9/9/2008

5
Dahlia will participate in singing her favorite TV songsby imitating the actions. We will know she can do this when she imitates
simple actions that her Mom, Dad, and older sister show her,imitatingat least 3 actions during one song.
Dahlia has imitated some simple actions when she sees them on her favorite TV shows, such as clapping and stomping her feet.
When Dahlia hears someone from her family singing one of the songs she recognizes, she will come over to the TV.
Dahlia loves balls and likes to put them into containers and then dump them out.
Family will:
Write down the actions from the favorite shows to start with.
The Primary Service Provider (ECSE)will:
Brainstorm with the family how to help Dahlia start imitating them using the favorite songs. This may include using consistent cues or phrases that Dahlia can recognize to help prompt her for the
actions. Also think about how to reinforce Dahlia for using the actions, such as singing the song again. Brainstorm with family how to use Dahlia's interest in balls and containers for imitation, e.g. shake
the container, dump it into a box,roll the ball over to the container, etc. Discuss and determine the best cues/phrases/prompts to use for actions. Model how to use them for the family and then have the
family try it out too. Discuss and determine other routines and child interests which can be used to promote this outcome. ECSE visits will be more frequent in the beginning, as often as needed to allow
for the kinds of supports the family needs to learn how to support this outcome (e.g. modeling, feedback, etc.).
The ECSE and the SLP will: make joint visits to discuss with the family the cues and phrases that could be used, along with other
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.
The goal will be measured monthly by the family and the PSP through observation and report.
Other: ______________________________
/
20
March 2014 5
9/9/2008
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:
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
9/9/2008
X. Transition Plan
A transition plan should be completed for children as identified in the Special Considerations section.
Transition Outcome/Goal:
Transition Document Dates:

Infant/Toddler: 03/04/2011 Preschool: 09/04/2011
Date transition notification sent: Date Intent to Register sent/given to Parent/Guardian:
Transition meeting held on: Date Intent to Register received from Parent/Guardian:
Transition plan initially developed on: 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 decisions about the kinds of supports PSP, preschool teacher,
09/04/2011
she might need and also how she will react to being around other children principal, family
Dahlia will make visits to the preschool room over the summer. PSP, principal, family 09/04/2011
school personnel,
The kindergarten teacher, school SLP,preschool teacher, and family will attend the Autism conference in April. 09/04/2011
principal, family, SC
PSP, family, SC,
Discuss transportation needs - both for spring and summer visits, as well as in the fall when Dahlia starts preschool. 09/04/2011
principal
March 2014 9

Individualized Family Service Plan (IFSP) Individualized Education Program (IEP)

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Individualized Family Service Plan (IFSP) Individualized Education Program (IEP)

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Dahlia Prose

Childs Name: Date of Birth: __________________

Office of Child Development and Early Learning

Individualized Family Service Plan (IFSP)

Meetings for the IFSP/IEP

I. Demographics and IFSP/IEP Team Membership

Role Printed Name

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

Parent/Guardian Signature: __________________________

II. Child and Family Information

Summary of Family Information

III. Special Considerations

2. Is the child deaf or hard of hearing?

5. Does the child have communication needs?

6. Does the child need assistive technology devices and/or services?

8. Is this an IFSP for a toddler who is at least 2 years 3 months of age?

IV. Measurable Results/Outcome/Goal #____

Date of review: _____________

IV. Measurable Results/Outcome/Goal #____

Date of review: _____________

Contact Person & Phone Number: Agency:

Contact Person & Phone Number: Agency:

Service Coordinator Home 3/4/2011 9/4/2011 1 day/ month 30 mins/ a day

Contact Person & Phone Number: Agency:

Contact Person & Phone Number: Agency:

VI. Participation in Regular Early Childhood Programs

VII. Participation with Typically Developing Children

Dahlia does receive early interventions in her natural enviornment.

IV. Measurable Results/Outcome/Goal #____

Date of review: _____________

IV. Measurable Results/Outcome/Goal #____

Date of review: _____________

IV. Measurable Results/Outcome/Goal #____

VIII. Early Intervention Services during Scheduled Breaks - PRESCHOOL ONLY

IX. Revisions to the IFSP/IEP

Transition Document Dates:

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

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