Nebraska Individualized Family Service Plan (IFSP) -...

Nebraska Individualized Family Service Plan (IFSP) -Draft

Child's Name: Gracie Snow Phone:

Child's Birthdate: 10/27/2007 SSN: 509-45-9876Age: 2 yrs 5 mos Medicaid#: 456132678-90

Date of Referral to Early Intervention: 04/16/2010 Address: 477 Lyon street Topico, NE 68466Family's language choice: Date of Consent for Evaluation:

Additional language choice (optional): Date of Notice:

Family would like an Interpreter: Date of MDT:

Parent(s)/GuardianName Role Address

Sally Snow Parent 477 Lyon Street Topico NE, 68466Home Phone () Work Phone ()

Services Coordinator / Case Manager InformationIf you have any questions about this plan or any of the people working with your child,please call the person listed as the Services Coordinator / Case Manager.

Name: Phone: Agency/Address:

IFSP Meeting DatesType Secondary Role Date Date Sent

Initial Initial 04/26/2010

IFSP Previous Meeting DatesType Date Date Sent

CONFIDENTIAL

Student: Gracie Snow | School: Demo School | Grade: EI 0-2 | DOB: 10/27/2007 | SRS Student ID #1333098 DraftNEBRASKA INDIVIDUAL FAMILY SERVICE PLAN (IFSP) | page 1 EI-1 Rev 11/98 (57060)

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DATE: FAMILY CONCERNS AND DESIRED PRIORITIES:Gracie has a feeding tube and family have been given the go ahead to begin transitioningto food.

Gracie has a shunt because of her hydrocephalus. The family wants her to stay healthy.

Gracie does not move very much on her own. The family sees that she wants to be withthem and would like her to be more independent in getting around.

Gracie screams, cries, and can make a few sounds. It seems like they are purposeful but itshard to know what she wants. The family wants help with ways to help her communicate.

Gracie is up frequently at night. The family would like to get some respite so that they canget caught up on their sleep.

Parents would like to go back to work but need a childcare provider who can adequatelycare for Gracie's needs and who they can be comfortable with.

Family would like to utilize Services Coordination.

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DATE: CHILD AND FAMILY STRENGTHS:CONFIDENTIAL


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CHILD'S PRESENT LEVELS OF DEVELOPMENT

Vision

Area/Date of Evaluation Child's Age Current Abilities

Hearing


Health/Status


Cognitive/Thinking Skills


Communication Skills


Social/Behavior Skills


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Self-Help/Adaptive Skills


Fine Motor Skills


Gross Motor Skills


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Goal / OutcomeGracie will eat with her family at dinnertime. We will know this goal is met when Gracie takes at least 5 bites ofsomething soft from a spoon when someone feeds her, i.e. applesauce, pudding, etc. during dinnertime at least 4nights per week.

Child / Family strengths and resources related to this goal:Gracie is very interested in food when the family is sitting at the table. She has been reaching toward it when she issitting on someone's lap.The feeding clinic has said that she can eat soft foods now.Gracie really likes to sit on her Dad's lap at the table.Gracie's parents have access to a nutritionist through the feeding clinic and will work with her in exploring atransition from the G-tube to eating by mouth.

What will be done / by whom:Gracie's family will:Have Gracie at the table with them when she is acting interested.Seat Gracie in her adapted chair at the table when she is actually trying some bites so that she can eat safely.

Primary Service Provider (OT) will:Coordinate with the medical OT from the Feeding Clinic for any future recommendations.Brainstorm with the family about ways to encourage Gracie to try a variety of soft foods safely.Provide ideas to the family about exploring Gracie feeding herself when she and they are ready.

The PSP (OT) will participate in weekly team meetings and receive coaching from the rest of the early interventionteam which includes PT, SLP, ECSE and SC.

The Services Coordinator will:Be in contact with the family and team at least monthly to make sure that the IFSP is updated as needed and thatinformation is shared across the team.Help the family secure reimbursement for trips to and from the feeding clinic.

Progress will be reviewed by monthly by family, OT and SC through observation and family report.

Plan Review for this Goal:

Date: 10/26/2010

How much progress :5/28/10: Gracie is comfortable sitting in her adapted chair now and sits with the family at dinner time almost everynight.6/16/10: Reportedly, Gracie is interested in when the other children at childcare are eating now too and wants to bewith them at the table.7/26/10: Gracie has been taking a bite of soft foods now IF the family waits for her to open her mouth when theyshow her the spoon with the food on it.9/9/10: Gracie is taking 3-5 bites now at one sitting, even though its not every time at dinner.

Next Steps / Comments:Continue with this goal. Gracie is taking bites now at some mealtimes but it is not consistent. Also, the feeding clinichas given the okay for the family to try biting things like crackers. The family prefers to move slowly with thecrackers, however, and want to continue to focus on Gracie eating soft foods and just experiment with the crackers.

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Goal / Outcome : Goal MetGracie will have a way of moving from one room to another. We will know this goal is met when Gracie scoots orcrawls into the kitchen at least 4 mornings in a week when her sisters are eating breakfast and getting ready toleave for school.

Child / Family strengths and resources related to this goal:Gracie rolls everywhere but often bumps into things.Gracie has pushed herself backward a couple of times when trying to get to a toy.Gracie wants to be where her family is, particularly at mealtimes. She knows if someone is in the next room and sheis not, and says "ahh" or screams, especially if no one responds.

What will be done / by whom:Family will:Give Gracie a few minutes to come to them if they are in another room.Play down on the floor with Gracie and encourage her to follow (Gracie's sisters like to do this).See if a slick floor works better for scooting.

Primary Service Provider (OT) and the family will have access to the PT during joint visits to get additional ideasabout ways to help Gracie move more independently. For the first 2 months, the PT will make 2 visits with the OT, sothat he can demonstrate strategies that the OT can coach the family about movement. The OT will keep PT informedin between joint visits and following the first 2 months, will determine, with the family, the timing of subsequentvisits.

The PSP (OT) will participate in weekly team meetings and receive coaching from the rest of the early interventionteam which includes the PT, SLP, ECSE and SC.

The Services Coordinator will:Be in contact with the family and team at least monthly to make sure that the IFSP is updated as needed and thatinformation is shared across the team.The family is interested in pursueing medical physical therapy, the SC will help them get a referral from theirphysician and the OT and PT will help them decide which provider to go to.

Progress will be reviewed by monthly by family, OT, and SC through observation and family report.


Date: 10/26/2010

How much progress :5/28/10: The family has tried putting Gracie on the kitchen floor because there isnt any carpet on it. She has nowpushed herself backward several times to get to some of her toys.6/16/10: Gracie is getting better at rolling now from one place to the other instead of bumping into things. She cango from her room to her sisters' room if she hears them playing.7/26/10: Gracie pivoted on her stomach in a circle and then reached for her toys. She went forward a little ways!9/9/10: Gracie used her arms to pull herself forward into the kitchen from the hallway when her sisters were eatingbreakfast.

Next Steps / Comments:GOAL Met!

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Goal / OutcomeGracie will have a way of letting her family know what she wants/needs. We will know this goal is met when Graciehas at least 2 ways of communication (could be a sound, a sign/gesture, etc.) that she uses daily and her familyknows what each means.

Child / Family strengths and resources related to this goal:Gracie is saying "ah" to get Mom's attention if Mom is in another room.Gracie cries when something is bothering her.Gracie screams if she doesnt like something.Gracie will look at people when she is making sounds.

What will be done / by whom:Gracie's family will:Talk to Gracie when they are doing something with her.Start to offer Gracie two things to choose from and show them to her if possible.Say the word that describes what they think Gracie wants or is communicating.

Primary Service Provider (OT) will access the SLP and the ECSE during joint visits to:Discuss what Gracie might be doing and brainstorm with the family other ways to encourage communication.Discuss with family what movements Gracie already has and what she is capable of that could be used for gesturesor even signs.Explore switches which might be used for communication.

The SLP and the ECSE will make a joint visit with the PSP (OT) during the first month to discuss the possiblities forcommunication with the family and so that the PSP (OT) can coach the family about communication. The OT, SLP,and the ECSE will coordinate with the ATP program to determine assitive technology devices that might be neededand then schedule joint visits to demonstrate and plan for next steps.

The PSP (OT)will participate in weekly team meetings and receiving coaching from the rest of the early interventionteam which includes PT, SLP, ECSE and SC.

The Services Coordinator will:Be in contact with the family and team at least monthly to make sure the IFSP is updated as needed and thatinformation is shared across the team.Assist the family by providing information about adapted toy and switch lending library.

Progress will be reviewed by monthly by family, SC and OT through observation and family report.


Date: 10/26/2010

How much progress :5/28/10: If Mom/Dad offer Gracie a choice of two things, she will look at each when they say the name of it. Theycan only do this if she is in a good mood. If she is frustrated or already crying/screaming, she gets mad.6/16/10: A Big Mac was introduced as a communication option. Gracie likes to push the button because then it"talks" but she doesnt seem to be doing this to get something. Mom/Dad are using it if they think she wants "more"of something, like when she is being tickled, she loves this.7/26/10: Gracie is now pushing the Big Mac button for "more". Sometimes she makes a sound too and if Mom/Dadhear the "mmmm" sound they reward her with the toy just like when she pushes the Big Mac.9/9/10: Gracie is starting to reach for her Mom to pick her up if Mom waits. Sometimes Gracie will cry. Momreminds her to lift up her arms by touching under her arms.

Next Steps / Comments:Continue with this goal. Gracie is using a gesture to get someone to pick her up but Mom/Dad and team are notsure if she is using sounds and the communication device intentionally.

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Goal / OutcomeSandy and Joe will have a childcare provider they are comfortable with to care for Gracie so that they can go back towork, and can also catch up on sleep. We will know this goal is met when Sandy and Joe are able to resume theirregular work schedules and have a few full nights of sleep during the week.

Child / Family strengths and resources related to this goal:Sandy and Joe do have family members in the area who can provide respite or back up care if needed. They wouldlike to find a couple more respite providers.Sandy's work place has been very supportive and made adjustments to her work load and schedule.Sandy has been talking to Kids Care Kingdom about Gracie's needs. They have been open to learning more aboutwhat to do. This is the same place that Gracie's sisters went for childcare.

What will be done / by whom:Sandy and Joe will:Contact the SC to update Gracie's health.Relay any necessary information to the SC and team about Gracie's health and care from her physicians.Contact SC to sign up providers or discuss any needed changes in Waiver services.Contact/relay questions or requests for help to Gracie's team from the childcare provider that may help withtransitioning Gracie to spending time there.

Services Coordinator will:Assist in setting up childcare and respite services, help find additional providers if needed.Explore the option of SSI with family.Make a referral to DCP if approved for SSI.Complete needed paperwork for waiver services to continue and keep the family and waiver worker up to date.

Progress will be reviewed by monthly by family and SC through family report, papework completed,providers in place.


Date: 10/26/2010

How much progress :5/28/10 Family heard from SSI, they have been accepted. SC made referral to DCP. Waiver paperwork completed.6/16/10 Waiver approved - family authorized to receive respite and childcare. Family found someone through theirchurch interested in helping by staying overnight at the family home 2 nights a week. SC assisted with signing thisperson up for respite care. Parents have gone back to work. Family has chosen a childcare provider and this wasapproved by HHS.7/26/10 Family is accessing DCP and Waiver childcare and respite services, per amounts authorized. Sandy plans toreturn to work in August.

Next Steps / Comments:Continue with this goal. SC will submit paperwork for Waiver review in December.

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Are there special conditions for safe transportation for this child?

THE SERVICES THAT WILL BE PROVIDED TO SUPPORT ALL GOALS AND OBJECTIVES ARE:Service Where

Occupational Therapy ServicesOther:

HomeWhere Other:

How Often? How Much? Group/Individual? Natural Environment?

22 days/6 month period 45 min/day Individual YesWhen will the service Start / End? Who pays? Who's Responsible?

/ School district Primary Service ProviderOther:

1. Include a justification of the extent, if any, to which a service will not be provided in a naturalenvironment.2. General Notes

Service Where

Physical TherapyOther:

HomeWhere Other:



/ School districtPhysical therapist

Other:Joint visits with PSP


Service Where

ECSEOther:

HomeWhere Other:



/ School districtTeacherOther:

Joint visits with PSP


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Service Where

Speech-language therapyOther:

HomeWhere Other:



/ School districtSpeech pathologist

Other:Joint visits with PSP


Service Where

Services coordinationOther:

HomeWhere Other:


1 days/month 30 min/day Individual YesWhen will the service Start / End? Who pays? Who's Responsible?

/ Early Development Network Services CoordinatorOther:


Service Where

Respite careOther:

HomeWhere Other:


2 days/week 18 hrs/month Individual YesWhen will the service Start / End? Who pays? Who's Responsible?

/ Medicaid Waivers Respite Care ProviderOther:


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Service Where

Other-(Please specify)Other: Childcare

HomeWhere Other: Community based setting for

childcareHow Often? How Much? Group/Individual? Natural Environment?

3 days/week 120 hrs/month Group YesWhen will the service Start / End? Who pays? Who's Responsible?

/ Medicaid WaiversServices Coordinator

Other:Family


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IFSP TRANSITION PLANTransition Conference Date: Estimated Transition Date:

What needs to be done? Who is responsible? Time Line Date Completed

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Initial IFSP Date: 2010-04-26

CHILD / FAMILY TEAMTeam Members Present at the Meeting:Print Name Role Other Address & Phone Sig on File

Sally Snow Parent 477 Lyon StreetTopico NE, 68466

Name / Signature: Role: Address:

Others who are part of the Child/Family Team:

Name Role Address & Phone

Familyinitial forcopy ofpagessent

Name: Role: Address: Family initial for copyof pages sent

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PARENTS /FAMILY

I (we) understand the content of the IFSP and give consent for all services in theIFSP to begin unless indicated below. Yes No

I (we) understand that a copy of the IFSP will be distributed within 7 calendar days. Yes No

PARENT / GUARDIAN SIGNATURE

1: Date: Yes No ('Yes' indicates that signatureis on file)

2: Date: Yes No ('Yes' indicates that signatureis on file)

(If 'No' selected above, please explain)

Any Comments:

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Nebraska Individualized Family Service Plan (IFSP) -...

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