Section 1

Directions: To begin, review each item and answer those that are important to your child and family. The information from Section I should be helpful in the development of your child's IFSP/IEP and subsequent intervention plans. The form is designed to be used four times per year to permit monitoring changes in your child and changes in family priorities.

In this section, a number of questions are asked about the childs participation in daily, family, and community activities.

Daily Activities

Eating

1. Where, when, and with whom does your child usually eat breakfast, lunch, and dinner?

2. What kinds of food does your child eat?

3. Meals are usually enjoyable because

4. Meals can be difficult because

Date reviewed: ______________ Noted changes: __________________________

Sleeping

1 . What is your child's bedtime routine (time, activities)?

2. What is your child's nap routine (time, activities)?

3 Naptime/bedtime is usually enjoyable because

4. Naptime/bedtime can be difficult because

Date reviewed: ______________ Noted changes: __________________________

Dressing

1 . What dressing/undressing skills can your child do?

2. How do you help your child get dressed/undressed?

3. Dressing/undressing is usually enjoyable because

4. Dressing/undressing can be difficult because

Date reviewed: ______________ Noted changes: __________________________

Bathing/Showering

1. What bathing/showering activities can your child do independently?

2. What kind of help does your child need for bathing/showering?

3. Bathing/showering is usually enjoyable because

4. Bathing/showering can be difficult because

Date reviewed: ______________ Noted changes: __________________________

Toileting

1 . What is your child's toileting schedule?

2. What type of potty training are you using with your child?

3. Toileting is usually not a problem because

4. Toileting can be difficult because

Date reviewed: ______________ Noted changes: __________________________

Playing and Interacting

I . What are your child's favorite objects and toys?

2. What are your child’s favorite play activities?

3. Other children usually enjoy playing/interacting with my child because

4. My child's playing/interacting with other children can be difficult because

Date reviewed: ______________ Noted changes: __________________________

Communicating with Others

1 . How does your child communicate with others?

2. Can others understand your child?

3. My child's speaking and listening are usually not problems because

4. My child's speaking and listening can be difficult because

Date reviewed: ______________ Noted changes: __________________________

Family Activities

1. What family activities usually involve your child (e.g., going on family outings, playing games, making crafts)?

2. How does your child participate in family activities?

3. In what other family activities would you like your child to participate?

4. My child's participation in family activities is usually enjoyable because

5. My child's participation in family activities can be difficult because

6. What skills would you like your child to learn to help him or her participate more fully in family activities?

Date reviewed: ______________ Noted changes: __________________________

Community Activities

1. In what community activities does your child participate (e.g., attend church, go to parades, participate in community recreation center activities)?

2. How does your child participate in these activities?

3. In what other community activities would you like your child to participate?

4. My child's participation in community activities is usually enjoyable because

5. My child's participation in community activities can be difficult because

6. What skills would you like your child to learn to help him or her participate more fully in community activities?

Date reviewed: ______________ Noted changes: __________________________