Indiana
Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514
No One Left Outside provides source-based information. The issuing agency or plan decides eligibility, acceptance and availability.
Source / last checked DFR: Forms - 2026-11-02
- Form number
- 46514
DFR: Forms - Reviewed 2026-11-02
- What it is for
- Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514
DFR: Forms - Reviewed 2026-11-02
- Issuing agency
- Indiana Family and Social Services Administration (FSSA); this form appears in the DFR forms catalog.
DFR: Forms - Reviewed 2026-11-02
- Program
- First Steps Early Intervention System
Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514 - Reviewed 2026-11-02
- Jurisdiction
- Indiana
DFR: Forms - Reviewed 2026-11-02
- Category
- FAMILY SERVICE PLAN
Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514 - Reviewed 2026-11-02
- Form type
- form
DFR: Forms - Reviewed 2026-11-02
- Who fills it out
- Not listed yet. Call to confirm.
- How to submit
- Physician page only: return the signed copy of this page to the child’s Intake / Service Coordinator.
Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514 - Reviewed 2026-11-02
- Documents to include
- BASED ON THE ATTACHED SUMMARY OF THE CHILD’S PRESENT LEVEL OF PERFORMANCE AND EVALUATION INFORMATION, I AGREE THAT THE RECOMMENDED THERAPIES ARE NECESSARY AND APPROPRIATE AND MAY BE PROVIDED AS LISTED FOR UP TO ONE YEAR FROM THIS DATE.
Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514 - Reviewed 2026-11-02
- Languages
- English
Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514 - Reviewed 2026-11-02
- Official page
- https://www.in.gov/fssa/dfr/forms-documents-and-tools/forms
DFR: Forms - Reviewed 2026-11-02
- Direct form link
- https://forms.in.gov/Download.aspx?id=5289
DFR: Forms - Reviewed 2026-11-02
- Revision date
- R15 / 7-15
Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514 - Reviewed 2026-11-02
- Signature
- The contents of this completed IFSP have been fully explained to me. I give informed, written consent to implement the services described in this section of the IFSP confirmed by my signature on this form. I also acknowledge the following:
Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514 - Reviewed 2026-11-02
- Accessibility
- I understand that this form serves as my ten (10) day written notice of the actions being proposed / refused and have been given an explanation of why the action is being proposed / refused. I have received a copy of parent's rights and complaint procedures (under section 470 IAC 3.1-14-1) for the First Steps Early Intervention System and had these rights explained verbally by my Service Coordinator. The notice was written in language understandable to me and in my native language, or translated orally or by other means to my native language or other mode of communication. I understand that I may refuse any proposed service(s) / action(s) and my Service Coordinator will document my refusal.
Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514 - Reviewed 2026-11-02
- What the form says
The contents of this completed IFSP have been fully explained to me. I give informed, written consent to implement the services described in this section of the IFSP confirmed by my signature on this form. I also acknowledge the following: I understand that this form serves as my ten (10) day written notice of the actions being proposed / refused and have been given an explanation of why the action is being proposed / refused. I have received a copy of parent's rights and complaint procedures (under section 470 IAC 3.1-14-1) for the First Steps Early Intervention System and had these rights explained verbally by my Service Coordinator. The notice was written in language understandable to me and in my native language, or translated orally or by other means to my native language or other mode of communication. I understand that I may refuse any proposed service(s) / action(s) and my Service Coordinator will document my refusal.
Indiana's Individualized Family Service Plan to Enhance the Capacity of Families to Meet the Special Needs of Their Children 46514 - Reviewed 2026-11-02
Check the form number and revision before using it. Read the agency's privacy and consent terms before sharing personal information.