Free 51672.FH11 - Indiana

INDIVIDUALIZED FAMILY TRANSITION PLAN
State Form 51672 (R3 / 3-07) / BCD 0105

Name of child County Date of Transition Meeting (month, day, year)

Date of birth (month, day, year) IFSP date (month, day, year)

DISCUSSION OF TRANSITION OPTIONS Community based options:
Play group Mothers day out program Parks and recreation Library programs Other: ____________________________________________________

FINANCIAL RESOURCES
Review financial resource options, check all that apply: Private insurance Medicaid waiver Hoosier Healthwise CSHCS Private pay Other: _______________________________ In reviewing financial resources have you considered the following:

Head Start:

Child Care:

Is the provider enrolled in the network? Who will follow up?______________________ Who is the current waiver manager? ____________________________________

Private Preschool:

Is a prior authorization required? ____________________________________ Contact CSHCS Customer Service / Prior Authorization Unit (if applicable) to explore future service options.

Clinic Based Therapy:

Contact Hoosier Healthwise case manager Other: _______________________________ Disposition of Assistive Technology / Equipment [List equipment purchased by First Steps that continues to be used by the child and how the equipment will be (1) returned to FS, (2) purchased by the family or other plan.]

Local Educational Agency (Include contact name and telephone number):

Other Transition Options:

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INDIVIDUALIZED FAMILY TRANSITION PLAN (continued)
State Form 51672 (R3 / 3-07) / BCD 0105

Name of child

Date of birth (month, day, year)

NEXT STEPS / STRATEGIES FOR WORKING TOWARD TRANSITION (List what needs to be done and by whom.)

WHO IS RESPONSIBLE

TIMELINE / EXPECTED DATE OF COMPLETION

The Individualized Family Transition Plan (pages 1 and 2) will be retained in the childs EI Record and will become part of the IFSP.

Additional comments / notes:

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