Interventions (Treatment procedures and/or modalities) V. Services Needed to Achieve Early Intervention Outcomes PAYMENT NATURAL 1 Family Fee (I) FREQUENCY LENGTH / 2 Insurance METHODS** Start LOCATION eNTITLED Service Date Date 3 Medicaid (g) (# (# (a,b,c,d) x/wk/ month/once) min/visit) (Must be a natural Date 4. Funds Actual Projected setting unless End End 5. Local Funds Individual justified Projected 6. Part C Service 1. Service Coordination _______* ______* 2. 3. 4. 5. 6. 7. 8. * This is the minimum frequency and length of direct contact from your service coordinator. The frequency and length of service coordination actually provided will vary since service coordination is an active, ongoing process that changes based on your family’s priorities and needs. ** Methods: a = Coaching, including hands-on as appropriate b = Consultation c = Assessment d = Provision of assistive technology device of why early intervention outcomes can’t be achieved satisfactorily in a natural setting and a plan Justification with timelines and supports necessary to return early intervention services to natural settings:
Interventions (Treatment procedures and/or modalities) V. Services Needed to Achieve Early Intervention Outcomes eNTITLED Service FREQUENCY (# x/wk/ month/once) LENGTH (# min/visit) (g) / Individual (I) METHODS** (a,b,c,d) NATURAL LOCATION (Must be a natural setting unless justified PAYMENT 1 Family Fee 2 Insurance 3 Medicaid 4. Funds 5. Local Funds 6. Part C Projected Start Date Projected End Date Actual End Date 1. Service Coordination _______* ______* Service 2. 3. 4. 5. 6. 7. 8. * This is the minimum frequency and length of direct contact from your service coordinator. The frequency and length of service coordination actually provided will vary since service coordination is an active, ongoing process that changes based on your family’s priorities and needs. ** Methods: a = Coaching, including hands-on as appropriate b = Consultation c = Assessment d = Provision of assistive technology device Justification of why early intervention outcomes can’t be achieved satisfactorily in a natural setting and a plan with timelines and supports necessary to return early intervention services to natural settings:
IFSP_7-15_IFSP-HW.docx