Form Gci-1021e - Individualized Family Service Plan (Ifsp) Transition
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2GCI-1021E (8-16) – Page 1
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
IFSP Type:
Arizona Early Intervention Program (AzEIP)
IFSP Date:
INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP)
TRANSITION
CHILD’S NAME
DATE OF BIRTH
SCHOOL DISTRICT
DATE OF AzEIP ELIGIBILITY
DATE TRANSITION PLANNING MEETING DUE
DATE TRANSITION PLANNING
DATE TRANSITION CONFERENCE DUE
DATE TRANSITION CONFERENCE
Refer to AzEIP Transition Timeline
MEETING COMPLETED
Refer to AzEIP Transition Timeline
COMPLETED
By initialing below, I acknowledge that the Transition Planning Meeting steps needed to support my child and family’s
transition from early intervention have been discussed:
My service coordinator explained that the purpose of the Transition Planning Meeting is to discuss and document all of the
necessary steps to ensure my child and family has a smooth transition out of early intervention services at age 3.
A vision screening checklist must have been completed within the past 12 months;
Date of my child’s last vision screening:
A hearing screening must have been completed within the past 12 months;
Date of my child’s last hearing screening:
If a hearing screening has not been completed within the past 12 months, we will obtain one no later than:
I received information from my Service Coordinator to support me in obtaining a hearing screening for my child.
My service coordinator and team discussed with me the services and supports that may be available to my child and family
upon transition out of early intervention services, including tentative timelines, as documented below:
Preschool Options (i.e., developmental preschool, private or community preschools, Head Start):
Community Resources (i.e., home visiting programs, parent support groups or trainings):
Options available through my child’s health insurance and/or other public agencies:
My Service Coordinator discussed the need to provide informed consent before sharing information about my child and
family with any parties involved with my child’s transition process.
My family has the following questions, concerns and priorities regarding transitioning my child from early intervention
services:
As a result of these questions, concerns and priorities, IFSP Outcome(s) were specifically developed to support my child
and family. Refer to IFSP Outcome(s) #
.
PEA NOTIFICATION
Date PEA Notification Sent:
I understand that my Service Coordinator will provide a notification including
demographic information about my child and family to my local school district
and the Arizona Department of Education (based on the AzEIP Transition
Date parent opted out of Notification:
Timeline), unless I opt out of this notification by signing the opt-out portion of
the PEA Notification Referral form.
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