Form Gci-1021e - Individualized Family Service Plan (Ifsp) Transition Page 2
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2GCI-1021E (8-16) – Page 2
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
TRANSITION CONFERENCE PLANNING
I agree to have a Transition Conference and understand my Service Coordinator must send an invitation to
participate to a representative(s) from my local school district. Additionally, I would like the following people and/or
programs invited to the Transition Conference:
1.
2.
3.
4.
I do not agree to have a Transition Conference and understand my Service Coordinator will not coordinate a
meeting with my local school district.
Responsible Party
Additional Activities Prior to Exit:
Date Achieved
Initials
Child Exit Indicator summary completed.
My Service Coordinator and team provided me with an AzEIP Family
Survey, and explained the importance of completing it.
My Service Coordinator provided me a copy of my child’s record before
exiting early intervention.
If my child is eligible for an AHCCCS Health Plan, my child will be
referred to AHCCCS for continuum of services after the age of 3.
If my child is eligible for DDD, when my child turns 3 my family plans to:
Remain enrolled in DDD
Withdraw from DDD
If my child is not currently eligible for DDD, my Service Coordinator has
discussed the DDD eligibility requirements, and my Service Coordinator
and family plan to:
Complete the DDD application process at this time
Not complete the DDD application process at this time
Other:
Other:
Other:
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