ifsp_english · web viewnystagmus increases the likelihood that the child may have similar...

IFSP_English

RI Early Intervention Individualized Family Service Plan

Program Information

In Early Intervention

We want children of all

abilities to

1. Demonstrate positive emotional skills, including social relationships

1. Acquire and use knowledge and skills; including early literacy skills

1. Use appropriate behaviors to meet their needs

We want all families to

1. Understand their children's strengths, abilities, and special needs

1. Know their rights and effectively communicate their children's needs

1. Help their children develop and learn

My Childs Name:

DOB: Gender: |_| Male |_| Female

ID#: Referral Date:

Childs Address:

1.) Parent/Guardian:

Phone:

Email:

2.) Parent/Guardian:

Phone:

Email:

Service Coordinator

Phone: ext.

Email:

Parent Consultant:

Phone: ext.

Primary Care Physician:

PCP Address and Phone #:

IFSP Meeting Date: (Date the IFSP team meets to begin development of the IFSP)

45 days from referral is If the initial IFSP is over 45 days from referral indicate why:

|_| Child hospitalization |_| Family requested delay |_| Unable to contact/Family cancellation |_| Provider issue

IFSP Start Date: (Date the family agrees to and signs the IFSP)

6 Month Review Date

RBI Completion Date:

If this is an Interim IFSP complete Cover Page, page 10,11 and 13.



RI Early Intervention Individualized Family Service Plan, Revised 11.1.16 - Final IFSP Cover Page

RI Early Intervention Individualized Family Service Plan, Revised 11.1.16 Page 2

Childs Name DOB Age ID Date

Please describe the reason your child was referred to Early Intervention (EI):

General Health (Consider Childs growth/ development / medical history Pertinent family history or other important events Medications taken/reasons Established conditions Prematurity Pregnancy and birth summary (only if relevant to reason for referral)

Has your childs lead level been tested? |_| Yes |_| No

Is there a concern for a high lead level? |_| Yes |_| No

If Yes, Please explain.

Tell us about your childs nutrition and feeding (i.e. food preferences, diet, intake, swallowing, chewing):

Sleep? (i.e. hours, patterns, routines):


Tell us about your general daily activities? (i.e. diapering, bathing, behavior, going out in the community):

Does your child spend any time in a licensed early care and education setting? |_| Yes |_| No

Caregiver Location/Name:

Schedule

Hours/week

Does your child spend any time in the care of another non-parental adult? |_| Yes |_| No

Caregiver Location/Name:

Schedule

Hours/week

Please share any information that may be helpful in supporting your familys culture such as important holidays, cultural traditions, church, food, customs:


Your Family, Supports and Resources

Page 1

RI Early Intervention Individualized Family Service Plan, Revised 11.1.16


THIS PAGE SHOULD BE FILED SEPARATELY FROM THE IFSP AS IT MAY CONTAIN SENSITIVE INFORMATION.

Who lives with this child?

This will prevent it from being copied outside EI.

Are there any other circumstances affecting your child and family that could impact your childs development? (i.e. safety, homelessness, trauma, illness, loss, financial stress, depression, addiction)?

|_| Initial EcoMap developed. An ECOMAP is a picture of the supports that surround your family. This picture will help us to get to know you better. The space in the center represents who lives with your child. We will draw lines that connect your family to those around you. The thicker the line the more supportive the relationship. Broken lines or dashes represent relationships that cause you stress. Please consider extended family, friends, and places of worship, clubs, pediatricians or specialist or agencies like WIC. This information will help EI get a better picture of your familys supports and resources and will help us support you in the development of individualized ideas and strategies.

Caregiver 2 (Caregivers Family)

Caregiver 1 (Caregivers Family)

Caregiver 1 Friends

People at Work

Community Supports

Caregiver 2 Friends

People at Work

Community Supports

Community Supports and Services

Page 2A



Yes

No

1

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Does the parent have concerns about how the child hears?

2

|_|

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Have you noticed that the child does NOT startle in response to loud sounds? (< 6 months)

|_|

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Have you noticed that the child does NOT turn in response to sounds? (> 6 months)

|_|

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Have you noticed that the child does NOT follow simple spoken directions? (> 12 months)

3A

|_|

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Has the child failed a hearing screen? (newborn or other)

4

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Is there anyone in the family who has hearing loss from childhood? (including extended family)

5

|_|

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Is anyone concerned about your childs language development? Approximately how many words does he/she use consistently? ______________________________________________________

6

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Was the childs birth weight less than 3 pounds and 5 ounces?

7B

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Does the child have a syndrome associated with hearing loss?

8

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Has the child had meningitis?

9

|_|

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Has the child had middle ear infections or fluid in the ears for more than 3 months?

10

|_|

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Does the child have a craniofacial anomaly, such as cleft lip/palate, skin tags near the ear, an ear pit (small hole), or other atypical ear formation?

11C

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Did the child receive mechanical ventilation for more than 5 days?

12D

|_|

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Did the child have a congenital infection?

13

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Did the child have jaundice (hyperbilirubinemia) to the point of needing a blood transfusion?

14E

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Did the child receive ECMO?

15

|_|

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Did the child remain in the NICU for 5 or more days?

If any of the answers above are yes, it is recommended that you schedule a comprehensive hearing test for your child by a licensed pediatric audiologist. Testing will ensure your child is hearing all the sounds we would expect. A copy of this hearing screening should be given to the audiologist.

|_| Family has received RI Early Intervention Guide to Your Childs Hearing

A). Has the child failed a hearing screen? If the child was born in RI, results can be obtained with a signed release form from the RI Hearing Assessment Program, phone 401-277-3700, fax 401-276-7813. If the child was born out of state and the parent is unaware if their child was tested or what the results were, you can consult www.infanthearing.org to obtain contact information for that state.

B). Does the child have a syndrome associated with hearing loss? There are over 300 syndromes associated with hearing loss. This is a list those that are more common:

Achondroplasia

Fetal Alcohol Syndrome

Trisomy 13 or 18

Alpor

Hunter Syndrome

Trisomy 21 (Down Syndrome)

Apert

Neurofibromatosis

Turner

Charcot-marie-Tooth

Oculo-Auriculo-Vertebral Dysplasia

Usher

CHARGE Syndrome

Pendred

Waardenburg Syndrome

Crouzen or Cornelia de Lange

Treacher Collins

C). Did the child have mechanical ventilation for more than 5 days? Mechanical ventilation is defined as ventilation with intubation. Nasal cannula and CPAP are not considered mechanical ventilation.

D). Did the child have a congenital infection? Such as CMV (cytomegalovirus), herpes, toxoplasmosis, rubella, syphilis.

E). Did the child receive ECMO? ECMO (extracorporeal membrane oxygenation) is a device that takes over the work of the lungs and sometimes the heart. It works by pumping the blood through an artificial lung, similar to a heart-lung bypass machine used in surgery. In this area, infants usually must be transferred to Massachusetts General Hospital to receive this type of care.

RI Early Intervention Risk Assessment for Hearing Loss

or Change in Hearing Level

Rhode Island Early Intervention

Vision Assessment Questionnaire

Page 3


4



If any of the answers above are yes, it is recommended that you schedule a comprehensive vision assessment for your child with a pediatric aphthalmologist. A copy of this vision screening should be given to the ophthalmologist.

Yes

No

Questions

1

|_|

|_|

Is there a family history of serious childhood eye disease?*

2

|_|

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Do your child's eyes appear to cross, turn in or wander?

3

|_|

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Does your child squint in normal lighting?

4

|_|

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Does your child turn his/her head to an abnormal position when looking at things?

5

|_|

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Have you noticed back and forth movements of your childs eyes? (nystagmus)

6

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Does your child repeatedly poke at his/her eyes or repeatedly rock his/her head back and forth?

7

|_|

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Have your child's eyes been injured?

8

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Was your child born prematurely or on oxygen while in the hospital?**

9

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Does your child have any health condition that might affect vision? (refer to list below)***

10

|_|

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Do you have concerns or have you noticed anything unusual about your childs vision? (If yes, please specify)

11

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Are you or anyone else concerned that your child is not looking at faces, objects or activities happening around them?

* 1. A positive family history for childhood diseases, such as, childhood cataracts, strabismus, amblyopia (lazy eye), glaucoma, retinal problems, retinoblastoma, or nystagmus increases the likelihood that the child may have similar problems.

** 8. Children who were premature are at a greater risk for developing amblyopia, high myopia (nearsightedness), and strabismus.

*** 9. Conditions that require vision screening in infants and children include but are not limited to:

Down Syndrome

Albinism

Marfan Syndrome

Cerebral Palsy

CHARGE Syndrome

Galectesemia

Spina Bifida

Osteogenesis Imperfecta

Homocystinuria

Tuberous Sclerosis

Trisomy 13

Trisomy 18

RI Early Intervention Risk Assessment for Visual Impairment


Where was the evaluation conducted?

Was the childs behavior and participation typical? surprising? Please explain. Evaluation Team: (Including Family) Name/Role: Name/Role: Name/Role: Name/Role: Name/Role: Name/Role: Methods / Procedures Used For Evaluation/Assessment: Check all that apply: |_|Standardized tool

|_| Checklist |_| Review of medical record |_|Interview |_| Observation. Please list other methods and procedures on the lines below:

|_| Eligible: This child meets the eligibility criteria for early intervention services.

Check #1 OR #2

1. |_| Single Established Condition (Specify)

Primary Diagnosis: ICD-10 Code:

Secondary Diagnosis: ICD-10 Code:

2. |_| Significant Developmental Delay (Select Eligibility Category a, b, or c )

Primary Diagnosis: ICD-10 Code:

a) A delay of 2 standard deviations in at least one of the following area(s)

|_| Cognitive |_| Gross Motor |_| Fine Motor Skills |_| Expressive Communication

|_| Receptive Communication |_| Social Emotional |_| Adaptive Skills

b) A delay of 1.5 standard deviations in at least two of the following area(s)


|_| Receptive Communication |_| Social Emotional |_| Adaptive Skills

c) There is a significant impact on child/family functioning in the following area(s)


|_| Receptive Communication |_| Social Emotional

|_| Adaptive Skills |_| Vision |_|Hearing |_| Health |_| Family Circumstance

|_| Not Eligible: This child does not meet the eligibility criteria for EI services (Summarize on Form B). Reminder: Provide procedural safeguards and document on Services Rendered Form.

|_| Family declined Early Intervention services

Scores: Indicate Standard Score (SS) (This is the same as Composite Score) Results: Indicate if 2 SD or 1.5 SD, WNL (Within Normal Limits) or SIF (Significant Impact on Functioning). If result is less than 1.5 SD, indicate

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