EXAMPLES PROVIDED BY: Bridges for Families Birth to 3 Program

Initial IFSP Checklist

Things To Do Prior to the Initial IFSP (Early Intervention Team Meeting):

• Schedule the meeting with at least one member of the evaluation team and the family. (Or with the person who reviewed records for eligibility if it was a records review.)
• Send the EI Team Meeting Invitation to the family with an Early Intervention Rights brochure. If the service coordinator was present at the eval and eligibility was already determine by the full team, you can send the IFSP invitation rather than the EI Team Meeting Invitation. All invitations are in the J drive under LTR-MEMO. Modify invitations as appropriate (such as for a child eligible by diagnosis).
• Send some pages of the IFSP with the invitation to the family for them to complete, if appropriate. (options include: Community page, Routines page, Strengths/Challenges page, Outcome pages)
• Send a draft of the Early Intervention Evaluation Report to the family prior to the meeting if another team member has not already done so.
• Optional: fill in some information on the IFSP prior to the meeting such as demographics on all pages, developmental information from the eval report (Look At pages), transition information.

Things to Bring to the Initial IFSP Meeting:

• Blank IFSP to be developed (or the one you have begun to fill in)
• Copies of eval report or records review/developmental summary report to be signed at this meeting if there are no corrections to be made.
• Statement of Eligibility, to be filled out at this meeting.
• Consent to Access Insurance form, if applicable
• Birth to 3 Program HMO Exemption Request form, if applicable (for HMO disenrollment)
• Extra Release of Information Forms. Some examples of when these will need to be filled out are: to communicate with daycare providers and to provide services in a daycare setting, when a child has been seen or will be seen by a medical specialist, when there are other agencies involved, and when a child is approaching transition to school or other programs (forms may have been done previously). Be sure to try to get a release for the primary physician if this has not already been done, and note this on the Family Info page of the IFSP.
• Declaration of Income form
• An extra blank copy of the IFSP so the family can follow along as the plan is being developed
• The Polaroid camera
• Parental Cost Share information
• Katie Beckett Total Cost of Plan page, if appropriate

Information to Gather/Share and Questions to Ask the Family:

• Verify the child's health insurance
• Obtain Social Security number if not obtained previously (parents can refuse)
• Clarify the role of the ongoing Service Coordinator and discuss how much contact they would like with the SC within MA guidelines, at a minimum (one family or collateral contact every month; one face-to-face contact with the family every 3 months, child need not be present)
• Ask if they would like for us to send our report to the doctor or anyone else
• When discussing services for the child, ask the family when the child naps and what days/times/locations work best for receiving services
• Explain to the family that a copy of the IFSP will be sent or given to them at a future visit. Also, that copies will be sent to the provider(s) who will work with the family.
• Ask whether they would like the IFSP to be sent to anyone else (e.g., the daycare provider.)
• Remember to have signatures on the IFSP, Total Cost of Plan page, Declaration of Income form (if brought to the visit), eval report, Statement of Eligibility, and all releases.
• Review the Missed Visit Guidelines with the family

Things To Do Back at the Office:

• Complete the Post-Eval form and submit it to the main office.
• Complete the DHS eligibility form. Staple to it a copy of the evaluation report or records review/developmental summary report on which you have highlighted areas documenting the child's eligibility. Submit it to the main office.
• Email request for service(s) to Program Coordinator including the child's name, insurance, service requested, frequency requested, location of service (be specific- e.g. off of Buckeye Rd, east of Stoughton Rd) and any additional information or requests such as a particular provider preference, whether an interpreter is needed, best days and times of day for visit, etc.
• Submit the IFSP for review while waiting for a provider to be assigned. IFSP will be returned to the SC after review and data is entered.
• Hold the IFSP until a provider is assigned then fill in that information including the start date on the Summary of Services page and the Total Cost of Plan page. Return the completed IFSP to enter this new info into the database.
• Contact provider to call family to schedule visits. Share information as applicable.
• Contact family to give them name and phone number of provider once assigned and you have verified that they are available for the family. (Some service coordinators skip this step if they have told the family that the provider will be the one contacting them.)
• Send any pertinent written information to the provider (e.g., evaluation report, other medical reports, IFSP or pages of the IFSP). No release of information is needed for Bridges staff or outside providers who have a signed agreement to provide services for Bridges.

Office staff will copy the IFSP for the family and will give it to the provider or send it to the family.
Office staff will copy the IFSP and send it to any outside provider(s).
Office staff will file the original IFSP in the chart.
Office staff will copy the doctor's prescription and send it to an outside provider, as appropriate.

Areas that Must be Completed on the Initial IFSP Form:

• Child's first and last name on cover
• Child's first and last name at the top of every page
• Family Info page: thoroughly complete all information that applies to the family, also complete the eligibility line at the bottom using language from the report (not billing diagnosis language)
• Look At Me pages (2): all areas including the child's present levels of functioning either stating eval scores or referencing the eval report
• Our Strengths and Challenges page: strengths, resources, concerns and priorities of the family (A family could refuse to share this information.)
• Our Plan pages: desired outcome; how will we know we have made progress
• Transition page: fill in date of child's third birthday and other applicable information
• Summary of Services page: one complete line for SC and one complete line for each provider up through start date; names of all IFSP team members with their role, signature and initials; date of IFSP meeting. SC can use as needed for their frequency and intensity only. Frequency and intensity must be completed for all other providers. Duration must be completed for SC and providers, maximum of 12 months. If the child is turning 3 in less than 6 months, put the exact number of months left.
• Total Cost of Plan page (It is recommended to cost out the plan for every initial IFSP so that the family sees the value of their service. It is required for families who will have a cost share.)
• Any corrections on an IFSP are done using a single line cross-out and your initials.

Updated: 05/03