Family Name:

Date:

MODEL INDIVIDUAL AND FAMLY SERVICE PLAN

A) Demographic Information:
Client name:	CSA ID No:	Date of FAPT:

DOB:	Age:	Sex:	Race:

Parents/Legal Guardian:

Address:	Phone No:

Siblings:

Others involved:

B) Referral Information:
Initial Referral: YES NO	If NO, date of initial referral:

Reason for Referral to CSA:

Referral Agency:	Agency Case Manager:

Phone Number:	Email Address:

Does Youth Receive Special Education Services? YES NO If YES, date of last IEP:

School Division Currently Attending:	Grade:

Last School/L.E.A. Attended:

Disability? YES NO If YES, explain:

Is Youth in Custody of DSS? YES NO	Title IV-E? YES NO

Basis for Custody (indicate):	If OTHER, explain:

Has Youth had Criminal Charges: YES NO

Current Court Involvement: YES NO

Medicaid: YES NO	FAMIS: YES NO

Child Support: YES NO	Parental Co-Pay: YES NO

Other Insurance: YES NO

Current Medications (Doctor’s name, medication type, dosage and frequency):

C) Child and Family Strengths:

(Strengths related to Psychological/Behavioral/Emotional Functioning, Home Environment, School Environment and Legal-Custody Status):

Family Name:

Date:

D) Child and Family Needs:

(Needs related to Psychological/Behavioral/Emotional Functioning, Home Environment, School Environment and Legal-Custody Status):

E) Date of Last CAFAS: CAFAS Score:

F) Goals, Outcomes, Objectives, Strategies, Agency, Vendor/s, Service Dates, and Transition Discharge Plan:
Long-term goal(s):

Current priority goal(s):

Youth:
Desired

Outcomes	Strategies or

Services	Person/Agency/

Vendor Responsible	Units and Frequency	Begin and End

Dates
Family:
Desired

Outcomes	Strategies or

Services	Person/Agency/

Vendor

Responsible	Units and Frequency	Begin and End

Dates

Family Name:

Date:

What is needed to step down/discharge from this plan?

G) Mitigating Circumstances:

(Check all that apply)

System Factors:

Current placement is unsafe, presents risks to child-proposed service provides for safety

Community safety at risk

Limitation of community capacity for wraparound services

Legal requirements of child’s placement

Limitation of resources in the community

Other

Individual Factors:

Ineffectiveness of current treatment

Child’s unwillingness to cooperate with treatment

Family preferences for or against particular modalities/services

Limitations of resources of caregiver, family or extended family

Other

H) Level of Need (Score):

I) Next Review Date: Time:

Family Name:

Date:

PARTICIPATION AND CONSENT OF FAMILY ASSESSMENT AND PLANNING TEAM:

The undersigned had the opportunity to participate in the development of this Individual Family Service Plan. We understand the IFSP and, unless otherwise indicated below, agree with the IFSP and agree to cooperate with the implementation of the IFSP.

FAPT MEMBER SIGNATURE, AGENCY	COMMENTS

PARTICIPANT SIGNATURE	COMMENTS

PARTICIPATION AND CONSENT OF PARENT/GUARDIAN

I have had the opportunity to participate in the development of this Individual Family Services Plan (IFSP). I understand the IFSP and give my permission to the Family Assessment and Planning Team (FAPT) to implement the IFSP. I/We also agree with the implementation of the IFSP.

Signature of Parent/Guardian
Date

I had the opportunity to participate in the development of the Individual Family Services Plan (IFSP). I understand the IFSP, I do not agree with the IFSP and I do not give my permission to implement the IFSP.

Signature of Parent/Guardian
Date

CSA COORDINATOR SIGNATURE

Signature of CSA Coordinator
Date

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MODEL INDIVIDUAL AND

Office of Comprehensive Servi

2003-05-06

Sherri Hutchinson