Free 51310.FH11 - Indiana

INDIANA FIRST STEPS EARLY INTERVENTION SYSTEM EXIT SUMMARY
State Form 51310 (R2 / 2-07) / BCD 0087

Child and family First Steps ID Number

Child date of birth (month, day, year)

County of residence

Name of Service Coordinator

Telephone number

(
Date (month, day, year)

)

This survey is used to find out how First Steps services have helped children and families. It is a checklist to record what the child and family knows and can do as a result of First Steps. It is an assessment of how effective First Steps has been, NOT an assessment of child or family progress! Service Coordinator, please circle the number that the family feels best describes them right now. As at entry into the First Steps System, we know that families with children of different ages are filling out this form with you. Please help the family choose what best describes them at this time. If the family feels a statement almost describes them, but not quite, circle the number just below the statement. For example, if the statement under 3 almost describes the family you are interviewing, but not quite, circle the 2. This survey must be completed just before the familys transition from the First Steps Early Intervention System. It is strongly recommended that it be completed during the last face-to-face meeting the Service Coordinator has with the family. This survey can and should be used as part of an exit interview with the family. It can be used to review the progress that has been made during the child and familys time in First Steps. This information is confidential. It will not be shared with any other program. It will only be used to help the First Steps Early Intervention System do a better job for future children and families.
Have you moved since you started in First Steps? Yes No If Yes, what was the original First Steps ID number?

If there is a medical diagnosis, please list here:

Signature of parent or caregiver

Date (month, day, year)

SERVICE COORDINATOR ONLY
Unable to complete Exit Summary (please document attempts to schedule exit meeting with family)

NOTE: Many of the items on this survey were adopted from a survey that was developed by the Early Childhood Outcomes Center with support from the Office of Special Education Programs, U.S. Department of Education. Page 1 of 5

Name of child

Identification number

CHILD DEVELOPMENT An important outcome of First Steps is for children to learn important and essential developmental skills. The questions in this section provide a summary of the childs development and learning. Professionals who assessed the child and have accurate information about the childs development should complete this section. Please respond to all questions as accurately as possible. What is the childs current level of development? With the help of your familys service coordinator, please fill in the blank indicating the childs developmental age in months or AEPS test score for each area. If your child still experiences delays in a specific domain, please check if specialized services after First Steps are still needed and recommended. DOMAIN COGNITION
Developmental age

STATEMENT OF CHILDS CURRENT LEVEL OF PERFORMANCE Please provide developmental age or AEPS scores.
Developmental age AEPS score

SPECIALIZED SERVICES AFTER FIRST STEPS STILL NEEDED
Yes No

OR
AEPS score

PHYSICAL DEVELOPMENT *
Developmental age

OR
AEPS score

Yes

No

COMMUNICATION
Developmental age

OR
AEPS score

Yes

No

SOCIAL / EMOTIONAL
Developmental age

OR
AEPS score

Yes

No

ADAPTIVE

OR

Yes

No

*Physical Development is defined as motor skills, vision and hearing.

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FAMILY OUTCOMES SURVEY (Exit)
UNDERSTANDING YOUR CHILDS STRENGTHS, ABILITIES, AND SPECIAL NEEDS 1. Your child is growing and learning. How well do you understand your childs development? 1 2 3 4 5 6 We are just beginning to understand our childs development. We have a basic understanding of our childs development, but still have a lot to learn. We have a pretty good understanding of our childs development. 7 We understand our childs development very well.

2. Some children have special health needs, a disability, or delays in their development. How much do you know about your childs special needs? 1 2 3 4 5 6 7 Right now we do not know very much. We have learned some things, but still have a lot of unanswered questions. We know a lot, but still need or want to know more. We are confident that we know most of what we need to know right now.

KNOWING YOUR RIGHTS AND ADVOCATING FOR YOUR CHILD 3. A variety of programs and services may be available for your child and family. Do you know what is available for your child and family? 1 2 3 4 5 6 7 We are just beginning to learn about the programs and services that are available. We know about some programs and services, but still have a lot to learn. We think we are aware of most available programs and services. We are very aware of the programs and services that are available.

4. Parents often meet with professionals to plan services or activities. How comfortable are you participating in these meetings? 1 2 3 4 5 6 7 Right now we are very uncomfortable participating in meetings. We are not very comfortable participating in meetings, but we do it anyway. We are pretty comfortable participating in meetings. We are very comfortable participating in meetings.

5. All parents want what is best and needed for their child to help them develop and learn. How well do you feel you can share your childs needs with professionals? 1 2 3 4 5 6 7 We need to feel a lot more We are beginning to feel more We can usually share our childs We feel very comfortable sharing our comfortable before sharing comfortable sharing our childs needs and ask our providers for childs needs and requesting help our childs needs, including asking needs and requesting help from help to meet his or her needs. from professionals. questions or asking them for help. professionals. 6. Families of children with special needs have rights, and there are things you can do if you are not satisfied. How well do you know your rights and what to do if you are not satisfied? 1 2 3 4 5 6 7 We are not sure about our rights or what to do if we are not satisfied. We understand our basic rights but are not sure about all of our options if we are not satisfied. We think we know most of our rights and what to do if we are not satisfied. We are very aware of our rights and know exactly what to do if we are not satisfied.

HELPING YOUR CHILD DEVELOP AND LEARN 7. All parents help their children develop and learn, but sometimes it is hard to know what to do. How would you describe your ability to help your child develop and learn? 1 We need to know a lot more about how to help our child develop and learn. 2 3 We know the basics of helping our child develop and learn, but still have many questions. 4 5 We feel pretty sure that we know how to help our child develop and learn. 6 7 We are very sure that we know how to help our child develop and learn.

8. All parents try to help their children learn to behave the way they would like, but sometimes it is hard to know what to do. How would you describe your ability to help your child learn to behave the way you would like? 1 We need to know a lot more about how to help our child behave like we want. 2 3 We know the basics of helping our child behave, but still have many questions. 4 5 We feel pretty sure that we know how to help our child behave. 6 7 We are very sure that we know how to help our child behave.

HAVING SUPPORT SYSTEMS 9. Many people feel that talking with another person helps them deal with problems or celebrate when good things happen. Does your family have someone you trust to listen and talk with you? 1 2 3 4 5 6 7 Right now, we really dont have We can probably find at least We usually have other people that There are definitely people in our anyone we can talk with about one person we could talk with, we can talk with about things. lives we can talk with whenever the things that are happening but are not very satisfied with we need to. in our lives. the situation. 10. Families sometimes must rely on other families, associations and community organizations for information, help or for emotional support when they need it. Do you know how to get help if you need or want it? 1 We usually handle things by ourselves, but would like to know more about other resources. 2 3 We know about some community resources we could use, but wouldnt mind more information. 4 5 We usually have resources we can use when we need to. 6 7 We have access to a variety of friends and community resources, and use them whenever we need to.

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FAMILY OUTCOMES SURVEY (Exit) - (continued)
HAVING SUPPORT SYSTEMS (continued) 11. Most families have things they enjoy doing. How much is your family able to do the things you enjoy? 3 4 5 6 We are able to participate in We are able to participate in many some of the things we enjoy, of the activities we enjoy. but not nearly as much as we would like. HEALTHY, SAFE, AND WELL-NOURISHED CHILDREN AND FAMILIES 12. All children need regular medical care. Do you have the medical care you want for your child right now? 1 We do not have the medical care we want for our child. 2 3 We have some medical care, but still have a long way to go before it is what we want. 4 5 We have good medical care for our child. 6 1 Right now it is really difficult to do any of the things we enjoy. 2 7 We are able to participate in almost all of the activities we enjoy.

7 We have excellent medical care for our child.

13. All families want their child to be safe. How safe do you feel your home is for your child? 1 2 3 4 5 We are just beginning to learn about We are making changes in our We feel our home is safe, but we things like lead paint, safely storing home to make it safer, but still are not sure if we have done all dangerous items, car seats, smoke need information and assistance. of the things we could do. detectors and safe sleeping that will help us make our home safe. 14. Proper nutrition and a well-balanced diet are very important for children to grow up healthy and strong. How well do you feel you provide your child with nutritious meals? 1 Were not sure that our child is receiving the healthy, nutritious meals he or she needs. 2 3 We are learning more about healthy and nutritious foods, but still need information. 4 5 We are pretty sure we are providing our child with nutritious meals to keep him/her healthy. 6 7 We feel we have done everything to make our home a very safe place for our child.

6

7 We feel very comfortable that we know what to feed our child, and that his meals are very nutritious.

NATURAL ENVIRONMENTS 15. As children grow older, they are able to take care of their needs and participate more independently at home, such as feeding themselves at meal times, dressing themselves when they wake up, moving around the house, and playing by themselves. Taking your childs age into account, how well do you feel your child is able to independently participate in these daily routines at home? 1 2 3 4 5 6 7 Our child is an infant and is just Our child is becoming more Our childs independence is Our child is doing all the things a learning how to do these things. independent, but due to his or growing, but he or she still needs child his or her age should be doing. OR her age or special needs, still some help with things other Our child needs total assistance. needs a lot of help. children the same age are doing. 16. Many families have a need for quality childcare. By this, we do not mean occasional babysitting, but regular childcare, either part-day or full-day. How would you describe the childcare you have for your child right now? CHECK HERE IF YOU HAVE NOT WANTED CHILD CARE, AND GO TO QUESTION 17. 1 2 3 4 5 6 7 We do not have the childcare We have adequate childcare, We are satisfied with our childcare, We have excellent childcare for we want. but still have a way to go before but would like to explore other our child. OR it is what we want. possibilities. Because of our childs special needs we have decided not to look for it. 17. Many families want their child to play with other children or participate in religious, community, or social activities. How would you describe your childs participation in these activities right now? CHECK HERE IF YOU HAVE NOT WANTED YOUR CHILD TO PARTICIPATE IN SUCH ACTIVITIES, AND GO TO QUESTION 18. 1 2 3 4 5 6 7 Right now our child does not Our child participates in some Our child participates in many Our child has excellent participation participate in activities we want. social or community activities, social or community activities, in social or community activities. OR but we have a way to go before but we would like to do more. Because of our childs special needs, it is what we want. we have decided not to look for it. 18. Families need to be able to do things in the community such as shopping, visiting friends or relatives, going out to eat. How well is your family able to do these things? 1 We would like to be able to take our child with us when we go out, but right now it is very difficult. 2 3 We are able to do some things as a family, but we would like to find ways to make it easier for all of us. 4 5 We are able to do most of the things we would like to do, but occasionally find it difficult to take our child with us. 6 7 We take our child with us wherever we need to go.

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19. Why are your child and family leaving First Steps? (Please check one.) Our child no longer needs First Steps services. We have decided to find services elsewhere. Our child is three years old. 20. Have you had a planning meeting for your childs transition out of First Steps? Yes, 90 days or more before the third birthday (or the date your child leaves First Steps). Yes, less than 90 days before the third birthday (or the date your child leaves First Steps). No. 21. IF your child is turning 3 years of age AND you answered No to question 20, why did this meeting NOT happen? (skip this question if your child is not turning 3) My child did not become involved in First Steps until after that date had passed. I chose to wait until closer to my childs third birthday. I did not know about it. I chose not to have a transition meeting. 22. As your child and family leave First Steps, what choices have you made for your child? (Check all that apply.) 22.1 My child will attend a community child care or preschool program. Yes No 22.2 My child will get therapy from a hospital, clinic or private therapist. Yes No 22.3 My child will attend a Head Start program. Yes No 22.4 My child will be enrolled in the public schools Special Education program. Yes No If you checked Yes to any of the choices above: 22.5 A representative from that program did attend our 90-day transition meeting. Yes No 22.6 First Steps provided the information I needed to make these choices. Yes No

LEAVING FIRST STEPS

* If you checked yes for number 22.4, please answer this last section.
23. IF your child will be enrolled in the public schools Early Childhood Special Education program, did the following happen? 23.1 The school district was notified about our child during his/her 18th month. Yes No 23.2 The school district was given more information about our child during his/her 30th month. Yes No 23.3 The school district was invited to our 90-day transition meeting. Yes No 23.4 The school sent a representative to the 90-day transition meeting. Yes No

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