Early Support for Infants & Toddlers
Kids' Potential, Our Purpose
Practice Guide: Completing the Summary of Functional Performance
The Summary of Functional Performance is the part of the Individualized Family Service Plan (IFSP)
where the evaluation and assessment team, with input from the parent, synthesizes all the information
known about the child from a variety of sources and across settings to create a snapshot of the child’s
functioning relative to same-aged peers in each of three global outcome areas. This brief snapshot of
functioning includes a descriptive/narrative portion and informs the choice of a global outcome
descriptor statement for each of the areas:
Positive social/emotional skills;
Acquiring and using knowledge and skills (including early language/communication); and
Use of appropriate behaviors to meet their needs.
The Summary of Functional Performance also provides the functional, contextual information needed to
form functional contextual individualized outcomes for each child and family.
The information referenced in the Summary of Functional Performance includes, but is not limited to:
information gathered when completing the Child/Family Routines and Activities and Family
Concerns, Resources, Priorities sections;
information from all of the evaluation and assessment activities conducted by the program or from
outside sources and the child’s present levels of development;
any additional notes.
The Summary of Functional Performance builds on, but does not duplicate evaluation and assessment
information and therefore should not be copied directly from other sections of the IFSP. More detail on
the process is included in the ESIT IFSP Process and Resource Guide.
The note-taking guide on the following pages was designed to assist providers in organizing the
information obtained from the evaluation and assessment processes according to the three global
outcome areas. A blank form and an example form (that aligns to the "Kim" IFSP exemplar) are included
in this practice guide.
This guide also includes Global Child Outcomes Discussion Prompts to assist IFSP teams in writing
summaries of functional performance for the three global outcome areas.
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Information on Child Functioning
Note Taking Form
Child Name:________________________ Dates collected: From __/__/__ to __/__/__
For each outcome, record what the child does and does not do across settings and situations
noting how this compares to what would be expected for a child this age.
Positive Social Relationships
How does child relate to adults, relate to other children, follow rules in group situations? (See
discussion prompts)
Family report/
observations
Other caregiver
report/observations
Provider
report/observations
Structured
situation/testing
Acquiring and Using Knowledge and Skills
How does the child learn and apply new knowledge? How does the child think, reason,
remember, and problem solve? (Including understanding symbols and physical/social worlds;
See discussion prompts)
Family report/
observations
Other caregiver
report/observations
Provider
report/observations
Structured
situation/testing
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Taking Appropriate Action to Meet Needs
How does the child take care of his or her needs such as eating, dressing, using tools, and
getting from place to place? For children over 2, how does the child contribute to his/her own
health and safety? (See discussion prompts)
Family report/
observations
Other caregiver
report/observations
Provider
report/observations
Structured
situation/testing
Information on Child Functioning – Example (to be used with "Kim" exemplar IFSP)
Note Taking Form
Child Name:___Kim Doe___________ Dates collected: From 11/29/xx to 1/5/xx
For each outcome, record what the child does and does not do across settings and situations
noting how this compares to what would be expected for a child this age.
Positive Social Relationships
How does child relate to adults, relate to other children, follow rules in group situations? (See
discussion prompts)
Family report/
observations
Kim likes to watch her sister and the neighborhood children play
and seems to want to play with them.
Kim smiles and laughs in response to sister.
Kim doesn't play with other children her own age.
Kim's NG tube contributes to her irritability.
She fusses many times each day.
Other
caregiver/report
observations
Kim plays calmly with Mr. Doe’s parents when they visit.
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Provider
report/observations
Kim attempts to initiate play - bats at objects.
Kim has no way to communicate to her sister that she wants to
play.
Kim calms when held by familiar adults.
Structured
situation/testing
Kim attempts to imitate sounds.
Kim doesn't participate in cooperative games (pat-a-cake, peek-a-
boo).
Acquiring and Using Knowledge and Skills
How does the child learn and apply new knowledge? How does the child think, reason,
remember, and problem solve? (Including understanding symbols and physical/social worlds;
See discussion prompts)
Family report/
observations
Kim understands when her family members speak to her.
Kim can choose between toys, clothes, books, etc. She won't
always do it and doesn't initiate.
Kim likes toys that play music and make sounds.
Kim makes a guttural sound in the back of her throat in response
to mom talking to her.
Other caregiver
report/observations
na
Provider
report/observations
Kim recognizes some of her toys when they are named.
Kim responds to directions from mom with appropriate emotions.
Kim shows preference by moving arms and legs and smiling.
Kim does not babble.
Structured
situation/testing
Cognitive AEPS - 7 to 8 mo. with scattering to 14 mo.
Reaches for toys, touches pictures.
Taking Appropriate Action to Meet Needs
How does the child take care of his or her needs such as eating, dressing, using tools, and
getting from place to place? For children over 2, how does the child contribute to his/her own
health and safety? (See discussion prompts)
Family report/
observations
Mrs. Doe dresses Kim - Kim does not assist.
Kim is tube fed twice each day - she does not eat what the family
eats and must have special meals prepared for her.
Eats in an adaptive high chair.
Kim does not assist with bathing.
Kim knows what she wants but gets frustrated trying to get
others to understand.
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Other caregiver
report/observations
na
Provider
report/observations
Kim doesn't use toys as tools.
Kim holds objects but doesn't pick them up herself.
Kim reaches for toys and can move a little bit toward them.
Structured
situation/testing
AEPS - less than 6 mo - adaptive behavior, 4 to 6 mo - motor skills.
Global Child Outcomes Discussion Prompts
Outcome 1: Child has positive social relationships.
Thinking about relating to adults, relating to other children, and (for those older than 18 months)
following rules related to groups or interacting with others.
How does the child relate to his/her parent(s)?
How does the child relate to other relatives or extended family and close family friends (e.g.,
grandparents, aunts, extended kin, etc.)? Do these interactions with people differ depending on the
setting the child is in with these people?
How does the child interact with familiar caregivers (e.g., child care providers, babysitters)?
How does the child relate to strangers? At first? After a while? In different settings and using
different approaches?
How does the child interact with/respond to people in community settings (e.g., park, library,
church, grocery store, with neighbors on walks, at the bus stop, in restaurants, at playgroups or
outings, etc.)?
How does the child interact with/react to peers (e.g., at child care, in the park, in the neighborhood,
in brief interactions in stores or at restaurants)?
How does the child relate to his/her siblings, cousins, or kids he/she sees frequently?
What is the child’s eye contact with others like? Does it differ across situations or with different
people?
How does the child display his/her emotions?
How does the child read and react to the emotions and expressions of others?
How does the child respond to touch from others?
How does the child maintain interactions with people?
In what situations and ways does the child express delight or display affection?
In the child’s interactions, are there behaviors that may interfere with relationships or seem
inappropriate in interactions expected for the child’s age (e.g., screaming, biting, tantrums)? How
often does this occur? In what situations? In what situations does it not occur?
Does the child display awareness of routines? How?
How does the child respond to transitions in routines or activities? Are the child’s actions different
for familiar transitions versus new transitions, or different across settings or with different people?
How and in what situations are interactions with others initiated?
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How does the child engage in mutual activity (e.g., joint attention, communicate to convey desire to
engage, initiate interaction or play, follow rules for mutual games)?
Does the child seek out others after an accomplishment? How?
Does the child seek out others after frustration or when angry? How?
Does the child participate in games (e.g., social, cooperative, rule-based, with turn-taking)? What do
the child’s interactions look like in these situations?
Does the child display an awareness of rules and expectations? How? Does the child behave
differently in different contexts (e.g., quieter in church, more active outside)?
Does the child attempt to resolve his/her conflicts? How? What do these actions look like with
peers, parents, etc.?
How does the child respond when others are not attending to him/her?
How does the child respond when someone arrives? Someone new? Someone familiar? How does
the child respond when someone leaves?
Talk about the child’s functioning with regard to turn-taking, showing, and sharing? With adults?
With other children?
The next step for the team to consider in the summary of functional performance process: How
would you expect other children this age to act in these situations?
Outcome 2: Child acquires and uses knowledge and skills.
Thinking, reasoning, remembering, and problem solving; understanding symbols; and understanding the
physical and social worlds.
How does the child use the words and skills she/he has in everyday settings (e.g., at home, at the
park, at child care, at the store, with other kids, at child care, in restaurants, with different people)?
Tell me about a time when he/she tried to solve a problem (e.g., overcome an obstacle/problem
interfering with something important to him/her). What did he/she do?
What concepts does the child understand? Does the child incorporate these into strategies that
he/she uses to accomplish something meaningful? How?
How does the child understand and respond to directions and requests from others?
How does the child imitate others’ actions (e.g., peers, adults) across settings to learn or try new
things?
How does the child display understanding of differences in roles, characteristics, and expectations
across people and situations (with increasing age role understanding may change from immediate
household roles and differences to more external community helper roles)?
Can the child use his/her understanding to communicate problems or attempt the solutions that
others suggest (e.g., try new strategies that they haven’t thought of based on gestures or
suggestions using words they know)?
Can the child answer questions of interest in meaningful ways?
Does the child use something learned at one time at a later time or in another situation?
Does the child display an awareness of the distinctions between things (e.g., object characteristics,
size differences, differences in object functions)?
What does the child do if an action or a strategy attempted isn’t successful? (e.g., how does he/she
try to modify approach, show persistence, etc.?)
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How does the child demonstrate her/his understanding of symbols into concepts, communication,
and play?
How does the child interact with books, pictures, and print?
How does the child’s play suggest understanding of familiar scripts for how things work, what things
are related, what comes next, and memory of previous actions in that situation?
Does the child’s play show attempts to modify strategies/approaches and to try new things? How?
Are there kinds of knowledge and skills that are not similar to same age peers and/or that might
interfere with acquiring and using knowledge and skills?
The next step for the team to consider in the summary of functional performance process: How
would you expect other children this age to act in these situations?
Outcome 3: Child takes appropriate action to meet his/her needs.
Taking care of basic needs; getting from place to place and using tools; and (if older than 24 months)
contributing to own health and safety.
What does the child do when she/he can’t get or doesn’t have what she wants?
What does the child do when he/she wants something that is out of reach or hard to get?
What does the child do when he/she is upset or needs comfort?
What does the child do when she/he is hungry?
What does he/she do when he/she is frustrated?
What does the child do when she/he needs help?
How does the child convey his/her needs?
How are the child’s actions to seek help or to convey his/her needs different from one setting to
another? How do they differ with different people? (e.g., child care vs. home vs. community setting,
with parent vs. grandparent, familiar person vs. stranger)
Tell me about the child’s actions when dressing and/or undressing?
What does the child do before and after peeing and pooping?
What does the child do at mealtime (eating, drinking)? Are there differences across settings and
with different people?
How does the child get started playing with toys? What does the child do when he/she is interested
in a different toy than he/she has?
Tell me about the child’s actions/reactions with regard to hygiene (tooth brushing, washing
hands/face, blowing nose, etc.)?
Does the child show awareness of situations that might be dangerous? What does he/she do (give
examples, (e.g., to drop offs, hot stoves, cars/crossing streets, strangers, etc.)?
Are there situations when a problem behavior or disability interferes with the child’s ability to take
action to meet needs? How consistently? How serious is it? Does the child take alternative
approaches? What are those?
Are the actions the child uses to meet his/her needs appropriate for his/her age? Can he/she
accomplish the things that peers do?
How does the child respond to delays in receiving expected attention and/or help from others?
How does the child respond to challenges?
Does the child display toy preferences? How do you know?
How does the child get from place to place when desired or needed?
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What does the child do when she/he is bored? How does she/he amuse her/himself or seek out
something fun?
How does the child respond to problematic or unwanted peer behavior?
How does the child use materials to have an effect (e.g., drawing materials, tools, etc.)?
The next step for the team to consider in the summary of functional performance process: How
would you expect other children this age to act in these situations?
“Kim” Exemplar IFSP
Individualized Family Service Plan
Under Part C of IDEA, the IFSP is required to enhance the capacity of families to
meet the needs of children birth to age three who have developmental delays or disabilities.
Type and Date of IFSP: Initial IFSP January 5, 20xx Annual IFSP ________
Interim IFSP ________ IFSP Review ________
I. Child and Family Information
Child's Name:
Kim Doe
Date of Birth:
August 3, 20xx
Gender: Male Female
Parent’s/Guardian’s
Name(s):
Juanita Doe (mother)
Gunner Doe (father)
Surrogate Parent: Yes No
Address(es):
2345 Fruit Street
(mailing) PO Box 245
City/State/Zip:
Apple City, WA 96543
Apple City, WA 96543
Phone Number(s):
( 123 ) 394 – 8899
Work Home Cell
( 123 ) 822 – 9843 (Juanita)
Work Home Cell
( 123 ) 398 – 2132 ext. 12 (Gunner)
Work Home Cell
( ) -
Work Home Cell
( ) -
Work Home Cell
( ) -
Work Home Cell
Email Address(es):
Ethnicity:
Hispanic and White/Caucasian
Family’s Primary Language:
English
Is an Interpreter Needed? Yes No
Resident School District:
Apple City School District
Service Area:
Apple City
Alternate contact:
Arthur and Rachel Doe
Relationship to child:
Grandparents
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Address:
72 Core Court
City/State/Zip:
Apple City, WA 96543
Phone Numbers:
(123 ) 656 – 6792
(123 ) 345 – 6093 (Rachel)
( ) -
Work Home Cell
Work Home Cell
Work Home Cell
Email Address:
None
Who lives in your home? Mother (Juanita), Father (Gunner), Sister (Jana – Age 4)
Describe previous developmental evaluations/assessments, early intervention and/or therapy services received (if
any):
Kim was hospitalized on and off in Seattle for the first 14 months of life and Mrs. Doe reports that she did not want to be
referred to early intervention while Kim was in and out of the hospital every few weeks. The past three months have been
the longest she has been home and her primary care physician recommended early intervention.
Family Resources Coordinator’s Information
Family Resources Coordinator's
Name:
Laura Donaldson
Agency
Apple City Early Intervention
Agency Address:
1234 Main Street
City/State/Zip
Apple City, WA 96543
Phone Number:
( 123 ) 654 – 0987
Work Cell
Email Address:
Referral and Medical/Health Information
Referral Information
Referral Date:
November 29, 20xx
Reason for Referral:
Failure to thrive associated with cardiac anomalies, encephalitis, spasticity (most
likely cerebral palsy), and seizures.
Referral Source:
David Johnson, MD
Address:
85 Medical Drive
City/State/Zip
Apple City, WA 96543
Phone Number: ( 123 ) 234-2000
Fax: ( 123 ) 234-2001
Email Address:
Primary Care Information
Primary Care Provider’s Name:
David Johnson, MD
Address:
85 Medical Drive
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City/State/Zip
Apple City, WA 96543
Phone Number: ( 123 ) 234-2000
Fax: ( 123 ) 234-2001
Email Address:
Child Health Information
Summary of child’s health status based on review of pertinent records (This is includes child’s birth history,
medical conditions or diagnoses (i.e. allergies), illnesses, hospitalizations, medications, vision and hearing screenings,
other developmental evaluations):
Kim was born at 38 weeks and her delivery was normal. She experienced trouble feeding from birth and had her first
seizure when she was three days old. Tests done in the NICU discovered cardiac anomalies and encephalitis.
Kim was hospitalized off and on in Seattle for the majority of her first 14 months of life due to seizures, numerous viral
infections and significant nutritional issues. Kim has had a nasogastric (NG) tube since 5 months of age. Repeated efforts
have been made to wean Kim from the NG tube; however, her illnesses prevented that from occurring. Kim has been
home from the hospital since November 2010 and has been healthy since that time and Kim’s parents are ready to initiate
early intervention services. The primary care physician and his nutritionist have made significant gains in weaning Kim
from the tube feedings since that time due to improved health and weight gain. Kim is currently tube fed twice daily- at
noon and during the night. The goal is to ensure sufficient weight gain and removal of Kim’s NG tube by late summer.
Kim has been diagnosed with failure to thrive associated with cardiac anomalies, encephalitis, spasticity (most likely
cerebral palsy), and seizures.
She is being weaned off her seizure medication (Phenobarbital). Recent EEG shows no seizure activity. She takes no
other medication.
Kim has no known allergies.
Kim passed her newborn hearing/vision screens and all subsequent screens and there are no concerns at this time. Her
next well-baby check is at 18 months.
What else should the team know about your child’s health so we can better plan and provide services
for your child and family?
Kim’s seizures appear to be under control, the biggest health concern is getting her to take other food more consistently so
the NG tube can be discontinued.
II. Child/Family Routines and Activities
Understanding the routines and activities of children and families assists the team in identifying the numerous
learning opportunities that can support children’s learning and development.
Where does your child spend the day? Who is involved? How would you describe your child’s
relationship(s) with you and the people they spend the most time with in different settings?
Jana usually is up before Kim in the morning so Mrs. Doe has time to feed Jana and get her dressed before Kim gets up.
Mrs. Doe always gets her up and gets her dressed. This is a pleasant, relaxed time for both Kim and Mrs. Doe.
During the week when Mr. Doe is working, Mrs. Doe spends most of the time at home during the day with Kim and Jana.
She is beginning to do some errands with the girls during the day now that Kim is healthy – she had been doing shopping
at night when Mr. Doe could be at home with Kim. Getting out of the house is important for both Jana and Mrs. Doe, being
inside all day causes stress.
Kim eats small meals every 3-4 hours. She is tube fed twice a day, around 1:00 AM and around 1:00 PM – she will be
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weaned from the lunch feeding within the next week or so. Mrs. Doe prepares different foods for Kim than the rest of the
family and reports that his is frustrating for her.
Jana plays with neighborhood children almost every day and Kim likes to watch them play and seems to want to play with
them. Typically the neighborhood children come to the Doe’s home to play because other mothers don’t seem as
comfortable with Kim in their homes. The neighborhood children are very accepting of Kim and involve her in their play as
appropriate as they are Jana’s age (4 and 5). Kim doesn’t play with neighborhood children her own age.
Jana usually naps around 2:00 PM every day and Kim naps around 3:00. Mrs. Doe has about an hour each day to do
chores at home when both girls are napping. Jana goes to bed at night around 8:00 and Kim goes to bed around 9:30.
Mr. And Mrs. Doe usually go to bed around 10:00. If Kim went to bed with Jana, it would be great for Mr. and Mrs. Doe.
Kim’s grandparents (Mr. Doe’s parents) visit at least once per week (usually on Sundays). They are retired and live
nearby. When they visit, they play with the girls and Mrs. Doe is able to get chores done around the house and sometimes
rest, but she cannot leave the girls alone with the grandparents because they are “uncomfortable” feeding Kim and
spending long periods of time caring for her. Kim knows her grandparents and responds well to them. If they are playing
with her, she doesn’t notice whether Mrs. Doe is in the room. Mr. Doe is not home a lot due to his long hours of work at a
computer programming business and is not as comfortable caring for Kim as Mrs. Doe.
What are the things your child enjoys most (including toys, people, places, activities, etc.)?
Kim likes riding in the car. The Does have an adapted car seat for Kim that they obtained with guidance from the OT
at the hospital.
Kim likes to be read books by her grandparents. She also enjoys playing games with them (peek-a-boo, pat-a-cake)
She likes toys that make sound.
She likes to watch Jana and the neighbor children play. She especially likes Jana to interact with her, showing her
toys and books.
Kim enjoys being with most adults, especially her grandparents.
What does your family enjoy doing together and why? Who is involved? When does this occur?
Kim likes to play on the living floor with Jana. She does so several times a day. Jana likes to interact with Kim during
the play time, showing her books and toys, and attempting to engage her in play.
Mrs. Doe’s parents live close by and visit several times during the day each week. They almost always spend time
with Kim and Jana after church on Sundays.
What activities and relationships are going well?
Kim usually spends her day at home with her mom and sister.
Kim’s paternal grandparents spend time with Kim and her family almost every Sunday after the family returns from
church. Her grandparents are helpful with Kim and Jana.
Transporting Kim to the store, church, etc. is easy.
Kim spends about 30 minutes 2x/day playing on the living room floor with her sister.
What, if any, routines and activities do you find to be difficult or frustrating for you or your child?
Mealtime: Mrs. Doe would like to be able to have the family eat the same foods at mealtime and not have to feed
Kim different foods. Mrs. Doe has been working on introducing new textures and different foods over the past
several months. Kim still gags when new textures/tastes are introduced but gagging reduces as she adjusts to the
foods.
Nap and bedtime: Mrs. Doe would like the girls to be on the same sleep schedule so she has some time to herself
and to do household chores.
What are the activities and routines your family currently does not do because of your child’s needs,
but is interested in doing now or in the near future?
Kim doesn’t go out to play with other children and have much interaction with children her age. Mrs. Doe would like
Kim to be around children her own age, especially since she really enjoys watching Jana play with neighbor
children. Mrs. Doe would like to explore some child care, respite care opportunities for Kim.
Mrs. Doe would like to have more support from Mr. Doe and Kim’s grandparents in caring for Kim and Jana. She is
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hoping that Kim’s grandparents will be more willing to help with Kim when she is able to eat table foods and not gag.
Mrs. Doe understands their reluctance and also recognizes that they are not in the best of health. She knows that
caring for Kim is stressful for them – they are afraid they will do something to ‘hurt” Kim.
Family Concerns, Resources, Priorities
Family’s concerns and priorities drive the development of IFSP outcomes. Family resources and supports are critical
for supporting and enhancing desired changes and children’s functioning and learning. Families should share only
the information they are comfortable sharing.
Summary of Family Concerns: (based on challenges in everyday routines and activities)
Kim gags and chokes when new foods/liquids are introduced and Kim’s mom has to spend a good amount of time working
to help Kim overcome her dislikes of new foods and textures – Kim’s mom is concerned about how long it will take to
transition Kim to table food that the rest of the family eats. Kim and her sister are not on the same sleep schedule (going
to bed, awaking in the morning or napping during the day) so Kim’s mom doesn’t always finish all of her chores and is
frequently tired as Kim does not yet sleep through the night. Several times a day, Kim cries and fusses because Kim’s
parents and sister do not always understand what she wants or needs. Kim attempts to initiate play with her sister but is
unable to move very far around the living room on her own and is unable to tell her sister what she wants to play with.
Kim’s grandmother doesn’t like to feed her because she gags/chokes on new foods. Kim is fed every 3-4 hours during the
day and is on a feeding tube at night. She wakes several times during the night taking 10-15 minutes to get back to sleep.
Priorities of the Family: (based on concerns identified above)
Kim’s mom has prioritized the following concerns to be addressed immediately by the team:
Would like Kim to sleep through the night and get both Kim and her sister on the same sleep routine so Kim’s mom
feels rested and better able to do daily chores.
Would like Kim to be able to gain enough weight to be off the night tube feeding and for Kim to be able to eat table
foods with the rest of the family at meal times.
Would like Kim to be able to let people know what she wants, especially during mealtime.
Her mother would like to find out more information about respite in the home or care for Kim in some way so she
can have a break.
Strengths, Resources that Family has to Meet their Child’s Needs: (include family, friends, community groups,
financial supports, etc. that are helpful to you)
Kim usually spends her day at home with her mom and sister.
Kim’s paternal grandparents spend time with Kim and her family almost every Sunday after the family returns from
church. Her grandparents are helpful with Kim and Jana.
Transporting Kim to the store, church, etc. is easy for the family.
Kim spends about 30 minutes 2x/day playing on the living room floor with her sister.
In addition to the information you have already provided, do you have any additional concerns that
you have not yet shared, or that others have shared with you about your child? Is there anything else
you like to tell us that would be helpful in planning supports and services with you to address what is
most important to your child and family?
Kim’s health may interfere with receiving early intervention, especially if she needs to be hospitalized again. Kim has many
doctors’ appointments, some of which are in Seattle.
I choose not to share information about my concerns, priorities and resources and/or
include this information in the IFSP. I understand that if my child is eligible, he/she can
still receive appropriate services as determined by the IFSP team even if I choose not
to complete this section.
________ (parent’s initials)
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III. Child’s Present Levels of Development
Understanding a child’s skills, as identified through evaluation and assessment (including observations, parent report,
testing), assists the team (including parents) in planning supports and services that enhance the child’s learning.
Developmental Area
Description of Skills/Status
(list child’s skills in each developmental
area/describe status; include information
about sensory needs in each domain )
Developmental
Level
(% of delay,
standard
deviation, age
equivalent)
Information
Source
(Instrument(s),
Parent report,
observation)
Evaluator’s
Name and
Evaluation/
Assessment
Date
Adaptive
Feeding, eating, dressing,
sleeping
(ex., holds a bottle; reaches for
toy, helps dress himself or
herself)
Able to drink a 1 ounce of liquid at a
time out of a cup held for her;
accepting a variety of foods (different
textures and tastes) by spoon; able to
hold spoon, but unable to bring it to
her mouth; not able to assist in
dressing or bathing motor challenges
impact her ability to participate in
independent feeding and/or dressing.
Under 6
months
AEPS, OT
report,
Parent
Interview
Alicia Jones,
12/15/xx
Susan Maula,
12/15/xx
Laura
Donaldson,
12/13/1xx and
12/15/xx
Cognitive
Thinking and learning
(ex., looks for dropped toy; pulls
toy on a string; does a simple
puzzle)
Watches people and very interested
in what is happening around her;
looks for toys when dropped or rolled
from view; likes toys with sound, and
shows some recognition of objects
when named, and recognizes mom,
dad, sister ,and grandparents; difficult
to determine Kim’s level of
understanding due to motor
challenges and limited ways of
communicating thoughts, wants and
needs.
7 – 8 months
with scattering
to 14 months
AEPS,
Parent
interview
Susan Maula,
12/15/xx
Laura
Donaldson,
12/13/xxand
12/15/xx
Expressive
Communication
Making sounds, gesturing,
talking
(ex., vocalizes vowels; points to
objects to express wants; uses 2
or more words)
Makes throaty sounds and gestures
to let her parents know what she
wants (i.e., when she wants to be
picked up, is full or doesn’t like a
food, or wants a particular book);
Enjoys sound play with adults and
children; attempts to imitate sounds
and toys that make sounds; her ability
to make sounds may be impacted by
the NG tube.
5-6 months
AEPS,
parent
interview,
observation.
Susan Maula,
12/15/xx
Laura
Donaldson,
12/13/xx and
12/15/xx
Receptive
Communication
Understanding words and
gestures
(ex., looks when hears name;
points to body parts and common
objects when named; follows
simple 1 & 2 step directions;
understands simple words)
Responds to her name; knows the
names of her family members and
looks in their direction when named;
recognizes the names of familiar
objects; pats at her choice when
offered books or toys; seems to know
colors and by patting on matching
colored objects when asked;
responds to her mother letting her
know what’s happening next (i.e.
stops fussing when Mom says “I’m
coming Kim!” or smiles and turns her
head when Jana invites her to play
12 – 15
months
AEPS, Parent
report,
Observation.
Susan Maula,
12/15/xx
Laura
Donaldson,
12/13/xx and
12/15/xx
Physical: Fine Motor
Using hands and fingers
(ex., reaches for and plays with
toys; picks up raisin; strings
beads)
Plays by reaching for, batting or
banging toy; pats pictures or objects;
holds toys, spoon, or other objects
when placed in her hand; limited
movement impacts her ability to
explore environment and play.
4 months
OT Report,
AEPS, Parent
report,
Observation.
Alicia Jones,
12/15/xx
Susan Maula,
12/15/xx
Laura
PRACTICE GUIDE: SUMMARY OF FUNCTIONAL PERFORMANCE
March 2014 Page 15
Developmental Area
Description of Skills/Status
(list child’s skills in each developmental
area/describe status; include information
about sensory needs in each domain )
Developmental
Level
(% of delay,
standard
deviation, age
equivalent)
Information
Source
(Instrument(s),
Parent report,
observation)
Evaluator’s
Name and
Evaluation/
Assessment
Date
Donaldson,
12/13/xx and
12/15/xx
Physical: Gross Motor
Moving and using large
muscles
(ex., rolls from tummy to back;
sits independently; walks holding
on)
Able to hold her head up when in her
adapted seat, held in a sitting or
standing position and on her tummy
or side; sits momentarily when
propped in a sitting position with her
hands on floor; able to roll by herself
from stomach to back with difficulty;
able to move short distances forward
when on tummy by twisting her body
to inch along); motivated to get her
toys.
6 months
AEPS, parent
report,
observation.
Susan Maula,
12/15/xx
Laura
Donaldson,
12/13/xx and
12/15/xx
Social/Emotional
Interacting with others
(ex., smiles and shows joy;
makes good eye contact; seeks
help from familiar caregivers;
takes turns; shares toys)
Enjoys being with familiar adults and
children; watches children and adults;
laughs and smiles at others; cries and
fusses when not understood; NG
tube affects her sleeping at night,
contributing to her being fussy during
the day.
6 – 9 months
AEPS,
Parent
interview
Susan Maula,
12/15/1xx
Laura
Donaldson,
12/13/xx and
12/15/xx
Vision
(ex., visually tracks object;
attends to faces of familiar
people; returns head to starting
point when watching slowly
disappearing object)
Follows people and toys as they move across her field
of vision; looks at pictures in books and enjoys toys with
lights and sound.
Newborn
screening,
observation,
parent report
NICU, Seattle
Grace
Memorial
Hospital –
August 5, 20xx
Laura
Donaldson,
12/13/1xx and
12/15/xx
Hearing
(ex., turns head, smiles, or acts
in response to voices and,
sounds; responds to name)
Turns head consistently to the sounds of her family’s
voices and to other sounds she finds interesting;
responds to her name; shows understanding of simple
phrases and words.
Newborn
hearing
screen and
subsequent
screens,
parent report,
observation
NICU, Seattle
Grace
Memorial
Hospital –
August 5, 20xx
Laura
Donaldson,
12/13/x and
12/15/xx
PRACTICE GUIDE: SUMMARY OF FUNCTIONAL PERFORMANCE
March 2014 Page 16
Initial Eligibility for Part C Services
The evaluation and assessment of each child and the determination of the child’s initial eligibility for Part C early
intervention services must include the use of informed clinical opinion. Eligibility determination is a team decision.
Your child is eligible for Part C Services because he/she has (check one or more below):
A 1.5 standard deviation or 25% delay in development in one or more areas (check all that apply):
Cognitive Physical: fine motor Physical: gross motor Adaptive
Social or emotional Expressive Communication Receptive Communication
A diagnosed condition that is likely to result in delay in development (identify): cerebral palsy
Informed Clinical Opinion (check if this is the only method used for determining eligibility):
Informed Clinical Opinion Summary (given that informed clinical opinion must be used throughout evaluation and
assessment, this section must be completed regardless of the criteria used to determine eligibility):
The IFSP team agrees that Kim is need of early intervention services to address the delays identified through her
evaluation as well as to address her family's concerns about her care and how they can best help her.
Summary of Functional Performance
Summarizing how a child uses skills in various domains to function across settings and situations provides
information that assists the team (including the parents) in developing functional IFSP outcomes and strategies to
meet these outcomes and so progress can be monitored over time. This information also assists in the completion of
the Child Outcomes Summary information.
Positive Social/Emotional Skills (including social relationships): (relating with adults; relating with other
children; following rules related to groups or interacting with others)
Summary of Child’s Functioning:
Most of Kim’s social skills are foundational; she is working on developing the building blocks that lead to age-expected
functioning in this area. Kim likes to play on the living room floor with her sister, Jana. They play together several times
a day. Jana initiates most play, showing Kim books and toys and attempting to engage Kim in play. Kim seems to enjoy
the interactions with her sister as shown by smiling and laughing in response to things her sister does. Kim attempts to
initiate play by batting at objects in the area of her sister, but she is unable to tell her sister what she wants to play with,
manipulate the objects in ways that allow much back and forth play, or move very far around the room.
Kim also enjoys watching Jana and neighborhood children play. She moves her arms and legs more when they are
nearby playing, as if she wants to play with them Kim appears to enjoy being with most adults. She expresses the
range of emotions and calms when held by familiar adults. Several times a day, however, she cries and fusses because
her parents and sister do not understand what she wants or needs. Her NG tube affects her sleeping at night, which
leaves Kim fussy during the day and difficult to interact with. When she is calm and focused, Kim sometimes attempts to
imitate sounds that her mother and Jana make. These actions demonstrate Kim’s understanding of turn-taking
effectively and will help her build age-expected skills with communicative turn-taking with other people next. The motor
movements in other cooperative turn-taking games like pat-a-cake and peek-a-boo still make these activities difficult for
Kim. Skills on the AEPS were demonstrated in the 6-9 month level and are consistent with this description.
PRACTICE GUIDE: SUMMARY OF FUNCTIONAL PERFORMANCE
March 2014 Page 17
Outcome Descriptor Statement (Select one):
Overall in this area, Kim is just beginning to show some immediate foundational skills which will help her work toward
age-appropriate skills.
Acquiring and Using Knowledge and Skills (including early language/communication): (thinking,
reasoning, remembering and problem solving; understanding symbols, understanding the physical and social worlds)
Summary of Child’s Functioning:
One of Kim’s strengths is her understanding of other’s words (AEPS was 12-14 month level). She shows recognition of a
number of toys and objects by looking at them when they are named and responds with appropriate emotion when she
hears her mother tell her what she wants her to do. This is an important building block to developing age-appropriate
understanding of simple commands and longer sentences. Kim also sometimes makes choices about which books and
toys she prefers, showing her differentiation between content and characteristics of different toys and books. However,
Kim does not yet initiate this activity; she chooses between books or toys when offered by others. She smiles and laughs
more when being shown toys that make sounds and play tunes. She shows her preferences by moving more in
response to or looking at the toy longer as well. Kim likes to listen to books and smiles when adults, especially her
grandparents, play games with her like peek-a-boo. She does not yet try to pull away the barrier in peek a boo herself or
problem solve how to get objects that are behind barriers or out of reach. Kim’s play has recently become more
interactive. It is mostly at a foundational level, but some skills are emerging that are the building blocks to functioning at
a level consistent with same age peers. On the cognitive items on the AEPS, scores were in the 7-8 month range with
scattering to 14 months. She reaches for and bats toys, touches pictures and makes sounds, watches what is
happening, and makes sounds in response to what happened around her. Mrs. Doe describes the sound as a “guttural
sound in the back of her throat.” She does not yet babble or make consonant sounds which will help build into use of
single words as symbols for objects or actions. On the AEPS, her expressive communication skills fell within a 5-6 month
level.
Outcome Descriptor Statement (Select one):
Overall in this area, Kim is just beginning to show some immediate foundational skills which will help her work toward
age-appropriate skills
Use of Appropriate Behaviors to Meet their Needs: (taking care of basic needs, e.g. showing hunger, dressing,
feeding, toileting, etc.; contributing to own health and safety, e.g., follows rules, assists with hand washing, avoids inedible
objects (if over 24 months); getting from place to place (mobility) and using tools (e.g., forks, strings attached to objects,
etc.))
Summary of Child’s Functioning:
Kim plays by reaching for and batting toys, patting pictures and banging toys. She holds objects when placed in her
hand (toys, spoon).
Kim has very early skills with regard to using appropriate behaviors to meet her needs (AEPS shows less than 6 months
for adaptive behavior and 4-6 months for motor skills). Kim knows what she wants, but several times a day Kim cries and
fusses when she is not understood and cannot convey those wishes using words or actions. When placed near her, Kim
is beginning to reach for and bat at toys, and sometimes is successful at hitting things or banging them into other
objects. She has not yet begun to use toys as tools to get other toys or interact with toys in sequences of exploratory
actions like other children the same age. She holds objects placed in her hand (toys, spoon), but is still working on
picking them up herself.
Kim eats mostly baby food, taking between 5-10 spoonfuls of food that is fed to her per meal, seated in an adapted high
chair. She is able to move food around in her mouth with her tongue, has good lip closure, and is starting to make
munching motions. Kim eats small meals every 3-4 hours. She is tube fed twice a day is on a feeding tube at night.
Gagging reduces as Kim adjusts to new foods.
Kim is not yet able to assist in dressing or bathing due to her motor challenges. Her limited movement also challenges
her ability to explore and play. She is able to move short distances forward (twisting her body to inch along) and is
PRACTICE GUIDE: SUMMARY OF FUNCTIONAL PERFORMANCE
March 2014 Page 18
motivated to attempt to get her toys, with occasional success at touching a toy, but not yet picking it up. Kim is
continuing to work on the skills that are the building blocks to skills other children her age are using to meet their needs.
Outcome Descriptor Statement (Select one):
Relative to children Kim’s age, Kim has very early skills in this outcome area. This means that Kim has the skills we
would expect of a much younger child in this area.
Date child outcomes descriptor statements were selected by the team: 01/05/xx
Assessment Team
The following individuals participated in the evaluation and assessment:
Printed name and Credentials
Role/organization
Assessment Activities
Laura Donaldson, Family Resources
Coordinator
FRC, Apple City Early Intervention
Child’s Present Levels of
Development
Eligibility for Part C Services
Contributed information for Summary
of Functional Performance
Participated in selection of Outcomes
Descriptor Statements
Alicia Jones, Occupational Therapist
OT, Apples and Oranges Occupational
Therapy
Child’s Present Levels of
Development
Eligibility for Part C Services
Contributed information for Summary
of Functional Performance
Participated in selection of Outcomes
Descriptor Statements
Susan Maula, Certified Early Childhood
Special Educator
ECSE, Apple City Early Intervention
Child’s Present Levels of
Development
Eligibility for Part C Services
Contributed information for Summary
of Functional Performance
Participated in selection of Outcomes
Descriptor Statements
Child’s Present Levels of
Development
Eligibility for Part C Services
Contributed information for Summary
of Functional Performance
Participated in selection of Outcomes
Descriptor Statements
Child’s Present Levels of
Development
Eligibility for Part C Services
Contributed information for Summary
of Functional Performance
Participated in selection of Outcomes
Descriptor Statements
Family role in Child Outcomes Summary process (check only one):
_x_ Family was present for the discussion and the selection of the descriptor statements
___ Family was present for the discussion, but not the selection of the descriptor statements
___ Family provided information, but was not present for the discussion
PRACTICE GUIDE: SUMMARY OF FUNCTIONAL PERFORMANCE
March 2014 Page 19
Family information on child functioning (check all that apply):
_x_ Received in team meeting ___ Collected separately _x_Incorporated into assessment
___ Not included (Please explain :)
Assessment instruments informing child outcomes summary:
AEPS
Other sources of information (e.g., practitioner observation; information from child care provider):
Observation of Kim at home with her family; parent interview; OT and special educator observation and report
IV. Functional IFSP Outcomes for Children and Families
Functional outcomes must reflect the changes families would like to see happen for themselves and their children
and be based on family priorities and the developmental needs of the child.
Outcome # 1 Start Date: January 10, 20xx
Target Date: July 1, 20xx
What would your family like to see happen for your child/family? (The outcome must be functional,
measurable and in the context everyday routines and activities.)
Kim will eat with her family at mealtime, eating the foods they eat and will choose what she wants to eat or drink by
touching pictures or pointing to the food or drink.
What’s happening now related to this outcome? What is your family currently doing that supports
achieving this outcome? (Describe your child and/or family’s functioning related to the desired change/outcome.)
Kim is taking between 5-10 spoonfuls of food per meal (mostly baby food) when seated in an adapted high chair. Kim is
not eating the same foods that her family eats during mealtime. Kim is starting to make munching motions. She is
swallowing liquids of varying consistencies, as well as soft foods, without choking. When new textures or foods are first
introduced, Kim chokes/gags. She is holding a spoon and waving it, but is not controlling the spoon to scoop food or
bring food to her mouth and does not finger feed. Kim is currently making throaty sounds and gestures to let her parents
know what she wants (i.e., when she wants to be picked up, or wants a particular book). During mealtime, she does not
indicated what she wants, only what she doesn’t want by closing her mouth and turning her head away or crying and
whining to refuse a drink or bite.
What are the ways in which your family and team will work toward achieving this outcome? Who will
help and what will they do? (Describe the methods and strategies that will be used to support your child and family to
achieve your outcomes within your daily activities and routines. List who will do what including both early intervention
services and informal supports, including family members, friends, neighbors, church or other community organizations,
special health care programs, parent education programs.)
Occupational Therapist (OT) will work closely with Kim and her family to address the priority of family mealtimes.
OT will use coaching strategies with family members to identify and try new foods and specific techniques to assist
Mrs. Doe in helping Kim to gain weight, eat the same foods as the family, and decrease Kim’s gagging and refusal
of foods.
OT will contact the nutritionist to identify additional appropriate high calorie textured foods, building on what Mrs.
Doe has already been feeding Kim.
Speech-language pathologist (SLP) will work with Mrs. and Mr. Doe, Jana and the grandparents to develop a
picture system for Kim to be able to express her wants and needs. Mealtime and snack time will be the first activity
settings to be addressed, but the SLP will support Kim’s successful use of a picture system over time across all
daily routines and activity settings with the important people in her life.
OT will provide occupational therapy services to Kim and her family.
Nutritionist will consult with Kim’s family and the OT to help with strategies to help Kim and her family be successful.
SLP will provide speech-language services to Kim and her family.
PRACTICE GUIDE: SUMMARY OF FUNCTIONAL PERFORMANCE
March 2014 Page 20
Outcome # 1 Start Date: January 10, 20xx
Target Date: July 1, 20xx
Mr. and Mrs. Doe and Kim’s grandparents will try the strategies and let the OT, nutritionist, and SLP know what is or
isn’t working and Kim’s progress towards this outcome.
How will we know we’ve made progress or if revisions are needed to outcomes or services? (What
criteria [i.e., observable action or behavior that show progress is being made], procedures [i.e., observation, report, chart],
and realistic timelines will be used?)
We’ll know this outcome is met when Kim eats at least two meals with family, sitting independently with or without
adaptive supports, eating regular table food, gaining at least one pound per month or 6 pounds in 6 months, and
using her picture system to indicate what she wants to eat or drink.
In three months, we’ll see how many textures and foods Kim is eating and decide if additional strategies or services
are needed at that time.
The use of the picture system will be under constant review and assessment to determine effectiveness and need to
add new pictures, use in different activity settings, and success of all family members’ use during daily routines.
Pediatrician will determine the rate of weight gain Kim needs to maintain in order to reduce and then stop night tube
feedings.
Mr. and Mrs. Doe will keep regular appointments with the pediatrician to monitor Kim’s weight gain and food intake.
How did we do? (Review of progress statement/Criteria for Success)
Date: __________________ Achieved: We did it!
Date: __________________ Continue: We are part way there. Let’s keep going.
The situation has changed:
Date: __________________ Discontinue: It no longer applies.
Date: __________________ Revise: Let’s try something different.
Date: ___________Explanations/Comments:
Outcome # 2 Start Date: January 10, 20xx
Target Date: April 1, 20xx
What would your family like to see happen for your child/family? (The outcome must be functional,
measurable and in the context everyday routines and activities.)
Kim will sleep through the night and take daytime naps and go to bed at the same time as her sister.
What’s happening now related to this outcome? What is your family currently doing that supports
achieving this outcome? (Describe your child and/or family’s functioning related to the desired change/outcome.)
Kim is not sleeping through the night. She has to be tube fed at 1:00 AM. Jana usually naps around 2:00 PM every day
and Kim naps around 3:00. Jana goes to bed at night around 8:00 and Kim goes to bed around 9:30.
What are the ways in which your family and team will work toward achieving this outcome? Who will
help and what will they do? (Describe the methods and strategies that will be used to support your child and family to
achieve your outcomes within your daily activities and routines. List who will do what including both early intervention
services and informal supports, including family members, friends, neighbors, church or other community organizations,
special health care programs, parent education programs.)
Special Instructor (SI) will provide early childhood special education services to Kim and her family.
SI and Mrs. Doe will explore information and resources about evidence-based strategies for putting children to bed
at the same time every day.
SI will share information and resources and support the Does to help implement changes in nap and bedtime
PRACTICE GUIDE: SUMMARY OF FUNCTIONAL PERFORMANCE
March 2014 Page 21
routines for Jana and Kim.
Pediatrician will help the Does monitor the night time feedings and Kim’s weight gain
Mr. and Mrs. Doe will share with the SI what is and is not working and their progress as a family meeting this
outcome.
How will we know we’ve made progress or if revisions are needed to outcomes or services? (What
criteria [i.e., observable action or behavior that show progress is being made], procedures [i.e., observation, report, chart],
and realistic timelines will be used?)
We will know this outcome is met when both girls successfully go down for a nap and go to bed at the same time
and night tube feedings are reduced or eliminated.
In two months, we will see how effective this new routine is for the family and decide if any additional supports or
services are needed at that time.
How did we do? (Review of progress statement/Criteria for Success)
Date: __________________ Achieved: We did it!
Date: __________________ Continue: We are part way there. Let’s keep going.
The situation has changed:
Date: __________________ Discontinue: It no longer applies.
Date: __________________ Revise: Let’s try something different.
Date: ___________Explanations/Comments:
Outcome # 3 Start Date: January 12, 2011
Target Date: July 1, 2011
What would your family like to see happen for your child/family? (The outcome must be functional,
measurable and in the context everyday routines and activities.)
Kim will get her own toys and go where she wants to go by moving herself on her own from one room to another
What’s happening now related to this outcome? What is your family currently doing that supports
achieving this outcome? (Describe your child and/or family’s functioning related to the desired change/outcome.)
Kim is able to roll by herself from her stomach to her back with difficulty. She is able to move short distances forward
(twisting her body to inch along) and is motivated to get her toys.
What are the ways in which your family and team will work toward achieving this outcome? Who will
help and what will they do? (Describe the methods and strategies that will be used to support your child and family to
achieve your outcomes within your daily activities and routines. List who will do what including both early intervention
services and informal supports, including family members, friends, neighbors, church or other community organizations,
special health care programs, parent education programs.)
.
Physical Therapist (PT) will work with Kim and Mr. and Mrs. Doe to identify, implement, and assess the
effectiveness of specific techniques and strategies the family will use to help Kim be successful in order for her to be
able improve her ability to get to her toys, move from one room to another, and get where she wants to go.
PT will consult with the Does about potential adaptive equipment that can assist Kim in being more mobile so she
gets to her toys.
PT will provide physical therapy services to Kim and her family to help implement strategies for successful
positioning and mobility.
Mr. and Mrs. Doe will try the strategies and activities in their everyday routines and share what is and is not working
and Kim’s progress towards this outcome.
PRACTICE GUIDE: SUMMARY OF FUNCTIONAL PERFORMANCE
March 2014 Page 22
How will we know we’ve made progress or if revisions are needed to outcomes or services? (What
criteria [i.e., observable action or behavior that show progress is being made], procedures [i.e., observation, report, chart],
and realistic timelines will be used?)
We will know that this outcome is met when Kim will be able to get from one room to another by using adaptive
equipment or by moving on her own.
In three months, we will meet to see how Kim’s mobility is changing and we will make any needed changes to
supports or services at that time.
How did we do? (Review of progress statement/Criteria for Success)
Date: __________________ Achieved: We did it!
Date: __________________ Continue: We are part way there. Let’s keep going.
The situation has changed:
Date: __________________ Discontinue: It no longer applies.
Date: __________________ Revise: Let’s try something different.
Date: ___________Explanations/Comments:
Outcome # 4 Start Date: January 17, 20xx
Target Date: May 1, 20xx
What would your family like to see happen for your child/family? (The outcome must be functional,
measurable and in the context everyday routines and activities.)
Grandparents will be comfortable babysitting Kim and Jana on Sunday afternoons so that Mr. and Mrs. Doe can use that
time to be away from home together as needed.
What’s happening now related to this outcome? What is your family currently doing that supports
achieving this outcome? (Describe your child and/or family’s functioning related to the desired change/outcome.)
Kim’s grandparents visit almost every Sunday afternoon. They are very comfortable babysitting Jana and enjoy playing
with Kim, but are nervous about feeding Kim and communicating with her when Mrs. Doe is not home.
What are the ways in which your family and team will work toward achieving this outcome? Who will
help and what will they do? (Describe the methods and strategies that will be used to support your child and family to
achieve your outcomes within your daily activities and routines. List who will do what including both early intervention
services and informal supports, including family members, friends, neighbors, church or other community organizations,
special health care programs, parent education programs.)
.
OT will work with Mrs. Doe and Kim’s grandparents to support their confidence and competence in caring for Kim
while Mr. and Mrs. Doe are away.
SI will work with Kim’s grandparents in creative ways to engage Kim in play using effective communication
strategies.
SLP will work with Kim’s grandparents in creative ways to engage Kim in play using effective communication
strategies.
OT will provide occupational therapy services to Kim, the Does, and Kim’s grandparents to help them feel confident
and competent in caring for Kim when the Does are not present.
SLP will provide speech-language services to Kim, the Does, and Kim’s grandparents to support the grandparents
in caring for Kim independently.
SI will provide early childhood special education services to Kim, the Does, and the grandparents to support the
PRACTICE GUIDE: SUMMARY OF FUNCTIONAL PERFORMANCE
March 2014 Page 23
grandparents in caring for Kim independently.
Grandparents will try the strategies and activities in their everyday routines and report back what is and is not
working, and Kim’s progress towards this outcome.
How will we know we’ve made progress or if revisions are needed to outcomes or services? (What
criteria [i.e., observable action or behavior that show progress is being made], procedures [i.e., observation, report, chart],
and realistic timelines will be used?)
We will know that this outcome is met when Kim’s Grandparents babysit her and Jana on Sunday afternoons
without Mrs. Doe being present.
In two months, we will meet to see how Kim’s Grandparents’ confidence is changing and we will make any needed
changes to supports or services at that time.
How did we do? (Review of progress statement/Criteria for Success)
Date: __________________ Achieved: We did it!
Date: __________________ Continue: We are part way there. Let’s keep going.
The situation has changed:
Date: __________________ Discontinue: It no longer applies.
Date: __________________ Revise: Let’s try something different.
Date: ___________Explanations/Comments:
Functional IFSP Outcomes Supported by the Family Resources Coordinator
Related to Accessing Community Resources and Supports
Family Resources Coordination is provided to all families enrolled in early intervention services. A Family Resources
Coordinator will help you identify and access community resources and supports that you or your child may need,
based on your current priorities. This page outlines the steps and activities that you and your team will take to
connect you with these resources.
Outcome # 1 What do we want to accomplish? (Desired Outcome)
Mrs. Doe will explore formal opportunities for Kim to spend time with children her own age, decide what (if anything) she is
interested in pursuing, and successfully enroll Kim as appropriate.
Start Date: January 31, 20xx
Target Date: March 1, 20xx
Who will do what? (Strategies/Activities)
Family Resources Coordinator (FRC) will provide Mrs. Doe with information on mother’s morning out programs,
community classes and playgroups and church preschool programs and discusses information with her.
FRC will assist Mrs. Doe in talking with and/or visiting any of these services/resources that Mrs. Doe would like to
explore.
FRC will assist Mrs. Doe with the necessary supports to enroll Kim in mother’s morning out, community classes and
playgroups or a church preschool program as appropriate. This includes accessing the necessary paperwork,
compiling the required information to complete the paperwork, and accessing any available financial resources
depending on the cost.
Review Date: ____________
PRACTICE GUIDE: SUMMARY OF FUNCTIONAL PERFORMANCE
March 2014 Page 24
Progress Code (circle one): Achieved Continue Discontinue Revise
Comments:
Outcome # 2 What do we want to accomplish? (Desired Outcome)
Mrs. Doe will find child care for both children so that she can run errands outside the home during the day once per
week.
Start Date: January 31, 20xx
Target Date: March 1, 20xx
Who will do what? (Strategies/Activities)
Family Resources Coordinator (FRC) will provide Mrs. Doe with information on respite services and potential
babysitting services and will assist Mrs. Doe in exploring these services/resources.
FRC will assist Mrs. Doe with the necessary supports to enroll in respite care or babysitting services. This includes
accessing the necessary paperwork, compiling the required information to complete the paperwork, and accessing
any available financial resources depending on the cost.
Review Date: ____________
Progress Code (circle one): Achieved Continue Discontinue Revise
Comments:
V. Transition Planning
The Transition Plan outlines steps and activities to support children and families leaving early intervention
and transitioning to other community or school services.
Priorities and goals for your child’s transition:
(Initial IFSP) Kim will attend the same neighborhood preschool and school as her sister Jana, at age 3.
Early Childhood Special Education Contact Information
Early Childhood Special Education
Contact’s Name:
Melissa Martinez
Phone Number ( 123 ) 922–0122
Work Cell
Email Address:
Transition Planning
Requirements and Activities
Action Steps
Role of Person
Responsible
Date
Initiated
Date
Completed
At any time from the initial IFSP meeting, up to 90 days before the child’s third birthday:
1. Discuss with parents what
“transition” from early
intervention means, including
eligibility and age guidelines
for early intervention services
Explained Part C services
and that Part C goes to age
3, at which time a transition
will occur.
Gave brief overview of
FRC
1/5/xx
1/5/xx
PRACTICE GUIDE: SUMMARY OF FUNCTIONAL PERFORMANCE
March 2014 Page 25
and what can be done to plan
for this transition.
transition planning relative to
Kim’s age.
2. Discuss with parents possible
program options (including
preschool special education
services; Head Start; child
care and other community
services) that may be available
when child is no longer
eligible.
3. Assist parents to understand
their rights and to develop
advocacy skills.
At least 90 days and no more than 9 months prior to the child’s third birthday:
4. Provide LEA and SEA
notification that the child is
potentially eligible for Part B
services (including child’s
name, address, phone number
and date of birth.)
5. With parental consent,
transfer records information
(including evaluation and
assessments and the IFSP).
At an IFSP meeting at least 90 days and no more than 9 months prior to the child’s birthday (that could
be the Transition Conference), develop the child’s Transition Plan, including the following and any
revisions to the functional child and family outcomes or early intervention and other services needed
to ensure a smooth transition:
6. Provide opportunity for parents
to meet and receive
information from the local
education agency or other
community program
representatives as appropriate.
7. Establish procedures to
prepare the child for changes
in service delivery, including
steps to help the child adjust to
and function in a new setting
(i.e. visit the new program,
meet with program staff prior
to the child’s first day, help
family secure materials and
supplies that will be needed
(such as a back pack.)
8. If the child is transitioning to
Part B, review with parents the
program options for their child
from the child’s third birthday
through the remainder of the
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March 2014 Page 26
school year
9. With parental agreement,
schedule the transition
conference (at least 90 days
and no more than 9 months
before the child’s third
birthday) and invite
participants including parents,
early intervention personnel,
local education agency, Head
Start, and other community
providers as appropriate.
10. At the transition conference:
a. Decide what other activities
need to be completed
before the child moves into
the new service setting
(including enrollment;
immunizations;
transportation issues,
medical needs etc.).
b. Review current evaluation
and assessment
information. Decide if any
further evaluations are
needed to determine
eligibility to Part B or other
programs prior to transition.
c. As appropriate, schedule
IEP meeting date if the child
will transition into preschool
special education.
d. Decide if there is a need for
post transition follow-up
(including service
coordination, consultation
with new staff).
11. Other transition planning
activities:
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March 2014 Page 27
VI. Summary of Services
Services and supports are determined following the development of functional IFSP outcomes. They are designed to
enhance the capacity of the family in supporting their child’s development and to promote the child’s learning and
development through functional participation in family and community activities.
* If setting is not a natural environment, complete the justification.
Early
Intervention
Services
Outcome #
(list all that apply)
Frequency and Length of
Services
Intensity
Method
Setting
Natural Environment
Y/N*
Payment Arrangements
(if any)
Duration
Agency(ies)
Responsible
Individual
Group
Start
Date
End
Date
OT
1,4
24, 1 hr
visits in 6
months
X
Direct
Service
Home
Y
Insurance
1/12/
xx
7/12
/xx
Apples and
Oranges
Occ.
Therapy
PT
3
12, 1 hr
visits in 6
months
X
Direct
Service
Home
Y
Insurance
1/12/
xx
7/12
/xx
Core
Strength
Physical
Therapy
SLP
1,4
12, 1 hr
visits in 6
months
X
Direct
Service
Home
Y
Insurance
1/12/
xx
7/12
/xx
Orchard
Speech
and
Develop.
SI
(ECSE)
2,4
12, 1 hr
visits in 6
months
X
Direct
Service
Home
Y
Part C
funds
1/12/
xx
7/12
/xx
Apple City
Early
Intervention
FRC
FRC
1-2
6 visits in
6 months
X
Direct
Service
Home
Y
Part C
funds
1/12/
xx
7/12
/xx
Apple City
Early
Intervention
Documentation of discussions to reach consensus about services: (Include discussions about any services refused or
declined, as well as any negotiations about frequency, intensity or method of service delivery, i.e., Discussed parents’ priority to work on
feeding now and wait for motor outcomes until later; Discussed team recommendation for 24 one hour visits for the next 12 weeks, parent
only wanted 12 one hour visits for the next 12 weeks.)
Discussed parents’ priority to work on feeding and sleeping and enhancing Kim’s ability to move on her own. Due to parent
priorities, Alicia, (OT), John (PT), Ana (SLP), and Susan (SI) services were recommended. Laura (FRC) will visit at least
monthly and suggested that she combine her visits with Alicia’s visits.
All services offered were accepted and the parents consented on the frequency and methods of service delivery.
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March 2014 Page 28
Other Services
These are additional services that your child and family are currently accessing, but are not entitled under Part C.
Such additional services may include medical services such as well-baby checks, follow-up with specialists for
medical purposes, etc.
Do you or your child currently receive any of the following services?
Check if
applicable
Financial & Other Basic
Assistance
Check if
applicable
Health and Medical
Services
Check if
applicable
General Services
Medicaid/Apple Health –
child
WIC Nutrition Program
Early Head Start or Head Start
Medicaid/Basic Health –
parent
First Steps
Migrant Head Start – American
Indian/Alaska Native Head Start
X
Health Insurance - child
X
Immunizations (Baby Shots)
Child Care
X
Health Insurance - parent
Family Planning Clinic
Home Visiting
Medicaid Premium Payment
Program
X
Well Child Care
Division of Developmental
Disabilities (DDD, non-EIS
services)
Food Stamps
Children with Special Health
Care Needs Program
Preschool
Financial Assistance
X
Primary care - parent
X
Other general services:
SSI
X
Medical specialists (i.e.
cardiology, neurology, etc.)
Parent to Parent (P2P) referral
Child Care subsidies
EPSDT/Medicaid Health Check
Washington State Fathers
Network (WSFN) referral
TANF
X
Dental care
X
Hospital OT does follow up
every 3 months for NG tube
issues
Other financial services:
Indian Health Services
Other health services:
Comments (include names, contact information and funding sources for above services as appropriate):
Primary care provider – David Johnson, MD – Apple City Pediatrics – (123) 234-2000 – Johnson@acpediatric.com
Nutritionist – Janie Smith, RN – Apple City Pediatrics – (123) 234-2000
Neurologist (team lead for Kim in Seattle that coordinates other specialists as well) – Dr. Shane Slocum – (123) 458-3817
(most recent team report attached)
Dentist – An Apple a Day Dentistry – (123) 458-3255
Hospital OT – Betty Davis, OT – Seattle Grace Memorial – (123) 458-3636 (most recent progress report attached)
What other services do your child and family need, and want to access?
Other Service
Provider
Steps to be Taken to Help Family Access These
Services or Funding Sources to be Used
Child Care
Little Tots or Other
Laura (FRC) and Mrs. Doe will begin exploring options.
Child Care Subsidy
DSHS
Laura (FRC) and Mrs. Doe will develop a plan about contacting
DSHS.
Respite Care
Apple City Parent Support
Center
Laura (FRC) provided pamphlet and will follow up with Mrs.
Doe.
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VII. Natural Environment Justification
Children learn best through natural learning opportunities that occur in settings where the child and family normally
participate. Early intervention supports and services must be provided in settings that are natural or typical for
children of the same age (i.e., natural environments). If the team decides that the outcome cannot be achieved in a
natural environment, a justification must be provided including why that decision was made and what we will do to
move services and supports into natural environments as soon as possible.
Outcome #
Service(s)/Support(s)
Setting
(Non-Natural Environment Setting Where
Service(s)/Support(s) Will be Provided)
Explanation of Why Outcome Cannot be Achieved in a Natural Environment:
Plan for Moving Service(s) and/or Support(s) into Natural Environments:
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VIII. IFSP Agreement
Prior Written Notice and Parental Consent for Provision of Early Intervention Services
Prior Written Notice:
Prior Written Notice must be provided to parents of an eligible child a reasonable time before the program proposes
or refuses to initiate or change the identification, evaluation or placement of the child or the provision of appropriate early
intervention service to the child and the child’s family.
Action Proposed:
To initiate the services listed on the IFSP for which consent is provided, according to the Summary of Services.
Reasons for Taking the Action:
After discussing all assessment information, including family observations and their concerns, priorities and
resources, the IFSP team, including the family, agreed on the early intervention services and other supports to be
provided to achieve desired outcomes.
Action Refused (if any):
Reasons for Refusal (if action refused):
Consent:
I participated in the development of this IFSP and I give informed consent for the Washington Early Support for
Infants and Toddlers program and service providers to carry out the activities listed on this IFSP.
Consent means I have been fully informed of all information about the activities for which consent is sought, in my
native language or other mode of communication; that I understand and agree in writing to the carrying out of the activities
for which consent is sought; the consent describes the activities and lists of records (if any) that will be released and to
whom; and the granting of my consent is voluntary and may be revoked in writing at any time. Such revocation is not
retroactive (it does not apply to any actions that occurred prior to revoking consent).
I understand that I may accept or decline any early intervention service (except the required procedural functions
under the regulations for Family Resources Coordination) and may decline such a service after first accepting it without
jeopardizing any other early intervention service(s) my child or family receives through the Washington Early Support for
Infants and Toddlers program. (NOTE: Complete the Declining One or More Early Intervention Services or Declining
Participation in the ESIT Program form if appropriate.)
I understand that my IFSP will be shared among the early intervention providers and program administrators
responsible for implementing this IFSP.
I have received a copy of Washington Early Support for Infants and Toddlers program, Individuals with Disabilities
Education Act (IDEA) Part C Procedural Safeguards [Parent Rights] along with this IFSP. This information includes the
complaint procedures and timelines I may use if I decide later that I disagree with any decisions. These rights have been
explained to me and I understand them.
Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent
Date
January
5, 201xx
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IFSP Participants that attended the IFSP Meeting:
Printed name and Credentials Role/organization Signature
Date
Gunner Doe
Father
January 5, 20xx
Juanita Doe
Mother
January 5, 20xx
Laura Donaldson, FRC
Apple City Early
Intervention
January 5, 20xx
Alicia Jones, OT
Apples and Oranges
Occupational Therapy
Alicia Jones, OT
January 5, 20xx
Susan Maula, SI
Apple City Early
Intervention
January 5, 20xx
Ana Erio, SLP
Orchard Speech and
Development
January 5, 20xx
John Smith, LPT
Core Strength
Physical Therapy
j.Smith, PT
January 5, 20xx
The following individuals did not attend the meeting but participated in the meeting through
conference call or in writing (specify which):
Printed name and Credentials Role/organization Conference Call/In Writing
David Johnson, MD
Apple City Pediatrics
Conference Call
Shane Slocum, MD (Neurologist)
Seattle Grace Memorial Hospital
In Writing
Betty Davis, OT
Seattle Grace Memorial Hospital
In Writing
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IX. IFSP Review
The IFSP is a fluid, flexible document that can be updated as you or your child’s and family’s needs change.
Reviews of the IFSP must occur every six months, and additional reviews can be held whenever changes are needed
to the IFSP. This page will summarize the changes being made to your child’s IFSP at each review.
Date of Review: ____________________________
Summary of Review Results (i.e., progress made towards outcomes or new outcomes developed; changes in the family’s
concerns, resources and priorities; changes to service provision; plans until next review, etc). Any changes to services and outcomes
noted in this review must also be updated in the appropriate section of the current IFSP.
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IFSP Review Agreement
Prior Written Notice and Parental Consent for Provision of Early Intervention Services
Prior Written Notice:
Prior Written Notice must be provided to parents of an eligible child a reasonable time before the program proposes
or refuses to initiate or change the identification, evaluation or placement of the child or the provision of appropriate early
intervention service to the child and the child’s family.
Action Proposed:
To initiate the services listed on the IFSP for which consent is provided, according to the Summary of Services.
Reasons for Taking the Action:
After discussing all assessment information, including family observations and their concerns, priorities and
resources, the IFSP team, including the family, agreed on the early intervention services and other supports to be
provided to achieve desired outcomes.
Action Refused (if any):
Reasons for Refusal (if action refused):
Consent:
I participated in the development of this IFSP and I give informed consent for the Washington Early Support for
Infants and Toddlers program and service providers to carry out the activities listed on this IFSP.
Consent means I have been fully informed of all information about the activities for which consent is sought, in my
native language or other mode of communication; that I understand and agree in writing to the carrying out of the
activities for which consent is sought; the consent describes the activities and lists of records (if any) that will be released
and to whom; and the granting of my consent is voluntary and may be revoked in writing at any time. Such revocation is
not retroactive (it does not apply to any actions that occurred prior to revoking consent).
I understand that I may accept or decline any early intervention service (except the required procedural functions
under the regulations for Family Resources Coordination) and may decline such a service after first accepting it without
jeopardizing any other early intervention service(s) my child or family receives through the Washington Early Support for
Infants and Toddlers program. (NOTE: Complete the Declining One or More Early Intervention Services or Declining
Participation in the ESIT Program form if appropriate.)
I understand that my IFSP will be shared among the early intervention providers and program administrators
responsible for implementing this IFSP.
I have received a copy of Washington Early Support for Infants and Toddlers program, Individuals with Disabilities
Education Act (IDEA) Part C Procedural Safeguards [Parent Rights] along with this IFSP. This information includes the
complaint procedures and timelines I may use if I decide later that I disagree with any decisions. These rights have been
explained to me and I understand them.
Signature(s) of (check one): Parent(s) Legal Guardian Surrogate Parent
Date
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IFSP Participants that attended the IFSP Meeting:
Printed name and Credentials Role/organization Signature Date
The following individuals did not attend the meeting but participated in the meeting through
conference call or in writing (specify which):
Printed name and Credentials Role/organization Conference Call/In Writing
