Form Gci-1021 Forff - Individualized Family Service Plan (Ifsp) Page 17
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18ARIZONA DEPARTMENT OF ECONOMIC SECURITY
GCI-1021I (2-17)
(IFSP Packet) - Page 17 of 18
Arizona Early Intervention Program (AzEIP)
IFSP Type:
INDIVIDUALIZED FAMILY SERVICE PLAN
IFSP Date:
INFORMED CONSENT BY PARENT(S) FOR SERVICES
CHILD’S NAME (First, M.I. Last)
DATE OF BIRTH
I have participated in the development of this IFSP and understand that I can accept or refuse any or all of the services
identified in the IFSP. I understand that my consent for services may be withdrawn at any time. Please initial and sign below.
1a. I agree with the proposed IFSP as written. I further understand that my signature below indicates that:
(a) I have been fully informed of the services being proposed and the reason for the proposal of services;
(b) my service coordinator explained my rights under this program; and (c) I give consent to carry out this
IFSP as written.
1b. I do not agree with the proposed IFSP as written (Prior Written Notice form must be completed and given
to the family).
However, I do consent to the following services/frequency:
2.
My service coordinator explained my rights under this program. I
Accept
Decline a written copy of
the AzEIP Family Rights Handbook.
3.
I have received a copy of the AzEIP Family Survey (Annual or Transition/Exit IFSP).
PARENT SIGNATURE
DATE
PARENT SIGNATURE
DATE
In addition to the release of this IFSP to team members, I give my consent for a copy of this IFSP to be sent to the individuals
or agencies listed below.
Name of individual/agency (e.g., pediatrician, Early Head Start program)
Purpose
PARENT SIGNATURE
DATE
I understand that I have agreed to disclose my IFSP to the person/agency listed above and that person/agency may not
disclose this IFSP to anyone else without my consent. This consent is valid for one year unless I revoke it at any time.
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