Free 51313.FH11 - Indiana

INDIANA FIRST STEPS EARLY INTERVENTION SYSTEM FAMILY INTERVIEW
State Form 51313 (R2 / 2-07) / BCD 0090

Name of child

Date of birth (month, day, year)

Child and family First Steps ID Number

County of residence

Name of Service Coordinator

Telephone number

(
Date (month, day, year)

)

One goal of First Steps is to help families to: work with the First Steps team to support their childs development; know their rights and be strong advocates for their child and family; keep their child and other family members safe and healthy; and connect to other families and community associations in times of emotional need. Another important goal of First Steps is for children to participate and be fully included in everyday activities, settings, and routines in the home and community. Federal and state law requires early intervention services to be provided in natural environments, those everyday activities, settings, and routines. Some of the questions provide a summary of the childs participation in home and community settings, and where early intervention services can logically take place. To meet these goals, we need to complete the following interview. This family interview will assist First Steps in identifying the knowledge, skills, and resources the family has or might need. Service Coordinator, please circle the number that the family feels best describes them right now. 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. Families, Service Coordinators are able to help you find information and make connections. They coordinate services for you. The items on this questionnaire do not mean that First Steps will be providing all the services you talk about. This information will be gathered by the Service Coordinator. If the Service Coordinator goes to the IFSP meeting, the family may request this document be completed over the phone before the meeting. If the SC cannot attend the IFSP meeting, this must be completed within the first 30 days during a face to face meeting with the family. As a family interview, it is optional and voluntary on the part of the family it is to be completed and shared only with the familys consent. This information is confidential. The information from this interview may assist the IFSP Team to identify needed support and services.

We have completed this Family Interview with our Service Coordinator.
Signature of parent or caregiver Date (month, day, year)

We have discussed the Family Interview with our Service Coordinator and have decided not to complete it.
Signature of parent or caregiver Date (month, day, year)

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 4

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 AEPS test score for each area. If your child still experiences delays in a specific domain, please check if specialized services through First Steps are needed and recommended. DOMAIN COGNITION
Fine AEPS score Gross AEPS score Yes No

STATEMENT OF CHILDS CURRENT LEVEL OF PERFORMANCE (Please provide AEPS scores.)
AEPS score

SPECIALIZED SERVICES ARE NEEDED
Yes No

PHYSICAL DEVELOPMENT *
AEPS score

COMMUNICATION
AEPS score

Yes

No

SOCIAL / EMOTIONAL
AEPS score

Yes

No

ADAPTIVE

Yes

No

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

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FAMILY OUTCOMES SURVEY
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 7 We are just beginning to We have a basic understanding We understand our childs We have a pretty good understand our childs of our childs development, but development very well. understanding of our development. still have a lot to learn. childs development. This is something I would like to have written into my IFSP as an outcome for our family. 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, We know a lot, but still need or We are confident that we know most but still have a lot of unanswered want to know more. of what we need to know right now. questions. This is something I would like to have written into my IFSP as an outcome for our family. 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 We are very aware of the programs We know about some programs We think we are aware of most the programs and services that are and services that are available. and services, but still have a lot available programs and services. available. to learn. This is something I would like to have written into my IFSP as an outcome for our family. 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 We are pretty comfortable We are very comfortable participating participating in meetings, but participating in meetings. in meetings. we do it anyway. This is something I would like to have written into my IFSP as an outcome for our family. 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. This is something I would like to have written into my IFSP as an outcome for our family. 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 We think we know most of our We are very aware of our rights and We understand our basic rights but what to do if we are not satisfied. rights and what to do if we are know exactly what to do if we are not sure about all of our options not satisfied. are not satisfied. if we are not satisfied. This is something I would like to have written into my IFSP as an outcome for our family. 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.

This is something I would like to have written into my IFSP as an outcome for our family. 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.

This is something I would like to have written into my IFSP as an outcome for our family. 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 Right now, we really dont have anyone we can talk with about the things that are happening in our lives. 2 3 We can probably find at least one person we could talk with, but are not very satisfied with the situation. 4 5 We usually have other people that we can talk with about things. 6 7 There are definitely people in our lives we can talk with whenever we need to.

This is something I would like to have written into my IFSP as an outcome for our family.

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HAVING SUPPORT SYSTEMS (continued) 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 2 3 4 5 We usually handle things by ourselves, We know about some community We usually have resources we but would like to know more about resources we could use, but can use when we need to. other resources. wouldnt mind more information. This is something I would like to have written into my IFSP as an outcome for our family. 11. Most families have things they enjoy doing. How much is your family able to do the things you enjoy? 1 Right now it is really difficult to do any of the things we enjoy. 3 4 5 We are able to participate in some We are able to participate in many of the things we enjoy, but not of the activities we enjoy. nearly as much as we would like. This is something I would like to have written into my IFSP as an outcome for our family. 2 6 7 We have access to a variety of friends and community resources, and use them whenever we need to.

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7 We are able to participate in almost all of the activities we enjoy.

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 7 We have excellent medical care for our child.

This is something I would like to have written into my IFSP as an outcome for our family. 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. This is something I would like to have written into my IFSP as an outcome for our family. 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 2 3 4 5 Were not sure that our child is We are learning more about We are pretty sure we are receiving the healthy, nutritious healthy and nutritious foods, providing our child with nutritious meals he or she needs. but still need information. meals to keep him/her healthy. This is something I would like to have written into my IFSP as an outcome for our family. 6 7 We feel we have done everything to make our home a very safe place for our child.

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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. This is something I would like to have written into my IFSP as an outcome for our family. 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 dont have the childcare we want. We have adequate childcare, We are satisfied with our childcare, We have excellent childcare for OR but still have a way to go before but would like to explore other our child. Because of our childs special needs it is what we want. possibilities. we have decided not to look for it. This is something I would like to have written into my IFSP as an outcome for our family. 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 participate in activities we want. OR Because of our childs special needs, we have decided not to look for it. Our child participates in some social or community activities, but we have a way to go before it is what we want. Our child participates in many social or community activities, but we would like to do more. Our child has excellent participation in social or community activities.

This is something I would like to have written into my IFSP as an outcome for our family. 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. 3 4 5 We are able to do some things We are able to do most of the as a family, but we would like to things we would like to do, but find ways to make it easier for occasionally find it difficult to all of us. take our child with us. This is something I would like to have written into my IFSP as an outcome for our family. Page 4 of 4 2 6 7 We take our child with us wherever we need to go.