Missouri Department of Elementary and Secondary Education

First Steps Forms

• About IFSP page
• What is an IFSP?
• The Cornerstones
• Developing an IFSP
• Forms
• Forms Video
• Early Intervention Practice Manual
• What's Next?
• Terms and Acronyms

Referral, Intake, and Eligibility Determination

• Referral Form (pdf or rtf)
  
• Neonatal Intensive Care Unit (NICU) Referral Form (pdf or rtf)
  
• Combined Enrollment Form and Social History Interview Instructions (pdf or doc)
  
• Combined Enrollment Form (pdf or doc)
  
• Social History Interview Form (pdf or rtf)
  
• Determination of Need for Educational Surrogate Appointment (pdf or doc)
  
• Early Intervention Record Access Log (pdf or doc)
  
• Health Summary (pdf or rtf)
  
• Getting to Know Our Child Worksheet (pdf or rtf)
  
• Getting to Know Our Child Instructions (pdf or rtf)
  
• Authorization Form - Evaluation/Assessment/Teaming (pdf or rtf)
  
• Assessment Reporting Guidelines (pdf or doc)
  
• Eligibility Criteria (pdf or doc)
  
• Eligibility Determination Documentation (pdf or doc)
  
• Eligibility Determination Instructions (pdf or doc)
  
• Meeting Notification (pdf or doc)
  
• First Steps Brochure Order Form (pdf or doc)
  
• Documentation of Referrals to First Steps Sample Letter and Form (pdf or doc)
  
• HIPAA Privacy Notice (pdf or doc)

IFSP Planning

• IFSP Planning Worksheet (pdf or doc)
  
• IFSP Planning Instructions (pdf or doc)
  
• "Identifying Typical Family Routines and Activities" Worksheet (pdf or doc)
  
• "Identifying Typical Family Routines and Activities" Instructions (pdf or doc)

IFSP Form

• Complete IFSP Form (pdf)
  
• IFSP Instructions for Completion (pdf or doc)

IFSP Form by Section

• Section 1 - Child Information (pdf or doc)
  
• Section 2 & 3 - Family Information (pdf or doc)
  
• Section 4 - Child's Present Abilities and Strengths:  Team Summary (pdf or rtf)
  
• Section 5 - Summary of Family Concerns, Priorities and Resources to Enhance the Development of Their Child (pdf or doc)
  
• Section 6 - Family and Child Centered Outcome(s) (pdf or rtf)
  
• Section 7 - Early Intervention Resources, Supports and Services (pdf or doc)
  -- 7a - Assistive Technology Authorization – IFSP Meeting Date (pdf or doc)
  -- 7b - Transportation Authorization (pdf or doc)
  
• Section 8 -  Natural Environments Justification (pdf or rft)
  
• Section 9 -  Other Services (pdf or rtf)
  
• Section 10 -  Transition Checklist (pdf or doc)
  
• Section 11 -  IFSP Development Team and Contributors (pdf or doc)
  
• Section 12 - IFSP Review Documentation Worksheet (pdf or doc)

IFSP Follow-up

• Physician Summary Form (pdf or doc)
  
• Physician Summary Instructions (pdf or doc)
  
• Provider/Service Coordinator Documentation Guidelines (pdf or doc)
  
• Service Coordinator Case Note (pdf or doc)
  
• Service Provider Daily Progress Report (pdf or doc)
  
• Service Provider Monthly Progress Report (pdf or doc)
  
• First Steps Change of Information and Inactivation Form (pdf or doc)

Insurance

• Information for Parents Regarding Use of Private Insurance  (pdf or doc)

Release, Consents, Notices

Notice of Action Form (Arabic) (pdf or doc)
Notice of Action/Consent Form (Arabic) (pdf or doc)

Notice of Action/Consent Form (Bosnian) (pdf or doc)
Notice of Action Form (Bosnian) (pdf or doc)

Release of Information Form and Instructions (English) (pdf or doc)
Notice of Action Instructions (English) (pdf or doc)
Notice of Action/Consent Form (English) (pdf or doc)
Notice of Action Form (English) (pdf)

Notice of Action/Consent Form (Japanese) (pdf or doc)
Notice of Action Form (Japanese) (pdf or doc)

Notice of Action/Consent Form (Russian) (pdf or doc)
Notice of Action Form (Russian) (pdf or doc)

Notice of Action/Consent Form (Somali) (pdf or doc)
Notice of Action Form (Somali) (pdf or doc)

Notice of Action/Consent Form (Spanish) (pdf or doc)
Notice of Action Form (Spanish) (pdf or doc)

Notice of Action/Consent Form (Vietnamese) (pdf or doc)
Notice of Action Form (Vietnamese) (pdf or doc)