Child’s Name: DOB BRIDGES ID #

Meeting Date: Type of IFSP: Initial IFSP Six Month Review

Change Review Annual Evaluation of IFSP

Parent Acknowledgements and Consents

Yes No I have received a copy of my rights under Part C of IDEA (Notice of Child and Family Rights in the BabyNet System) and these have been explained to me along with this IFSP. I understand that I will receive a copy of this IFSP, the results of any screenings, evaluations, and/or assessments conducted for this IFSP, and a copy of this signature page. My consent is voluntary and based on my understanding of the activities, which have been explained to me in my native language or mode of communication. I understand that my consent remains in effect until the next IFSP Review or Annual IFSP and that I may revoke my consent in writing, at any time. I understand that I may decline a service or services without jeopardizing any other BabyNet service(s) my child or family receives. I have participated in the development of this plan, and give informed consent for BabyNet to carry out the activity/activities on this IFSP. I understand that my IFSP will be shared among the BabyNet Service Providers implementing this IFSP, others I may identify, and entities within the system per federal reporting requirements.

Signature of Parent/Guardian(s) and Relationship: Date:

Signature of Parent/Guardian(s) and Relationship: Date:

Signature of Other IFSP Team Members Method Codes: A=Attended, P=Phone, E=Written Evaluation Only (not for ongoing service providers)

Signature/Name Role Agency

(if applicable) Method Code Date BN Service Coordinator

IFSP Consent and Team Signatures

October 2018 IFSP Consent and Team Signatures

INSTRUCTIONS

BABYNET IFSP CONSENT AND TEAM SIGNATURES

SCFS/BN017 rev March 2104

NOTE: A SEPARATE SIGNATURE PAGE IS REQUIRED FOR EACH IFSP TEAM MEETING, AND MUST

BE MAINTAINED IN THE HARD COPY PORTION OF THE CHILD’S BABYNET EDUCATIONAL RECORD

Child’s Name: Enter child’s name

DOB: Enter child’s date of birth

BRIDGES ID #: Enter child’s BRIDGES ID number

Meeting Date: Enter date of IFSP Team Meeting

Type: Select type of IFSP Team Meeting

Parent Acknowledgement and Consents:

Accepting BabyNet Part C Services Recommended by the IFSP Team Review the procedural safeguards, and all acknowledgements and consents with the family. The primary

parent/guardian is asked to initial either yes or no to each acknowledgment/consent.

Signature of Parent/Guardian(s) and Relationship:

The parent is asked to sign and date the plan. If the plan is not signed and dated by the parent/guardian, it is

not complete and services may not be initiated. Use the next line of parent signature to indicate the

participation of a second parent or guardian in development of the IFSP team meeting

Signature of IFSP Team Members and Method Codes

All other members of the IFSP Team that are present will sign, list their agency (if applicable), complete the

method code of their attendance, and enter the date of participation in plan development, review or evaluation. If

an IFSP team member participated in a manner other than face-to-face, the following documentation must be

provided:

1. if by telephone:

a. both the BNSC and BNSP will enter a service log in BRIDGES, or

b. the BNSC will fax the signature form to the BNSP, who will sign and return the document within 2

working days of the meeting; or

c. the BNSC and BNSP will hold a separate meeting in order to obtain the BNSP’s signature.

2. if the BNSP’s participation is by written evaluation/assessment, the report must be received prior to the IFSP

Team meeting and documented as such in BRIDGES.

October 2018 IFSP Consent and Team Signatures