Fillable INDIVIDUALIZED FAMILY SERVICE PLAN CONSENT AND TEAM SIGNATURES

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INDIVIDUALIZED FAMILY SERVICE PLAN CONSENT AND TEAM SIGNATURES

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SCDHHS/IDEA PART C/01JUL2020/ALL PREVIOUS VERSIONS ARE VOID
IFSP CONSENT AND TEAM SIGNATURES FORM
INDIVIDUALIZED FAMILY SERVICE PLAN
CONSENT AND TEAM SIGNATURES
SECTION 1: CHILD INFORMATION
Child’s First and Last Name:
DOB:
BRIDGES ID #:
Meeting Date:
Type of Individualized Family Service Plan (check one):
Change Review
Six Month Review
Annual Evaluation of
IFSP
Meeting Notes:
SECTION 2: ACKNOWLEDGMENTS AND CONSENTS
Parent’s Initials
Yes
No
I have received a copy of my rights under IDEA/Part C (Parent Notice of Family Rights and Safeguards) and
these have been explained to me along with this IFSP.
I understand that I will receive a copy of this IFSP, the results of any screenings, evaluations, and/or
assessments conducted for this IFSP, and a copy of this signature page.
My consent is voluntary and based on my understanding of the activities, which have been explained to me
in my native language or mode of communication.
I understand that my consent remains in effect until the next IFSP Review or Annual IFSP and that I may
revoke my consent in writing at any time.
I understand that I may decline a service or services without jeopardizing any other IDEA/Part C
service(s) my child or family receives.
I have participated in the development of this plan and give informed consent for IDEA/Part C to carry
out the activity/activities on this IFSP.
I understand that my IFSP will be shared among the Early Intervention Service (EIS) providers
implementing this IFSP, others I may identify, and entities within the system per federal reporting
requirements.
Signature of Parent
Date
Signature of Parent
Date
SCDHHS/IDEA PART C/01JUL2020/ALL PREVIOUS VERSIONS ARE VOID
IFSP CONSENT AND TEAM SIGNATURES FORM
SECTION 3: SIGNATURES OF IFSP TEAM (Method Codes: A=Attended, P=Phone, W=Written Evaluation Only)
Signature/Name
Role
Agency
(if applicable)
Method
Date
A
P
W*
Service Coordinator
*Written evaluation as a method of participation may only be used for the Initial IFSP.
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INDIVIDUALIZED FAMILY SERVICE PLAN CONSENT AND TEAM SIGNATURES

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Completed 6 March 2022

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