Support Plan (ISP) for a Child with Special Needs Form

INDIVIDUALIZED SUPPORT PLAN (ISP) FOR A CHILD WITH SPECIAL NEEDS

This form must be completed for a child whose cognitive, physical, social, emotional or communicative needs, or whose needs relating to overall development, are of such a nature that additional supports are required for the child. The plan must be developed in consultation with a parent of the child, the child (if appropriate for the child’s age) and any regulated health professional or other person who works with the child in a capacity that would allow the person to help inform the plan.

Student Information

Last Name

First Name

Date of Birth

Photo of Child (recommended)

INDIVIDUALIZED SUPPORT PLAN

1) HOW THE CHILD CARE PROGRAM WILL SUPPORT THE CHILD TO FUNCTION AND PARTICIPATE IN A MEANINGFUL AND PURPOSEFUL MANNER WHILE RECEIVING CHILD CARE:

2A) DESCRIPTION OF SUPPORTS, AIDS, ADAPTATIONS AND/OR OTHER MODIFICATIONS TO THE PHYSICAL ENVIRONMENT (if applicable):

2B) INSTRUCTIONS RELATING TO THE CHILD’S USE OF/INTERACTION WITH SUPPORTS OR AIDS OR THE ADAPTED/MODIFIED PHYSICAL ENVIRONMENT (if applicable):

3A) DESCRIPTION OF SUPPORTS OR AIDS, ADAPTATIONS OR OTHER MODIFICATIONS TO THE SOCIAL ENVIRONMENT (if applicable):

3B) INSTRUCTIONS RELATING TO THE CHILD’S USE OF/INTERACTION WITH SUPPORTS OR AIDS OR THE ADAPTED/MODIFIED SOCIAL ENVIRONMENT (if applicable):

4A) DESCRIPTION OF SUPPORTS OR AIDS, OR ADAPTATIONS OR OTHER MODIFICATIONS TO THE LEARNING ENVIRONMENT (if applicable):

4B) INSTRUCTIONS RELATING TO THE CHILD’S USE OF/INTERACTION WITH SUPPORTS OR AIDS OR THE ADAPTED/MODIFIED LEARNING ENVIRONMENT (if applicable):

Additional Information (if applicable):

CONFIRMATION

This plan has been created in consultation with the parent of the child, as defined in section 2(1) of the Child Care and Early Years Act, 2014.

This plan has been created in consultation with a regulated health professional or other person who works with the child in a capacity that would allow the person to help inform the plan (where applicable).

This plan has been created in consultation with the child (where appropriate for the child’s age).

Signature of Parent / Guardian (optional)

Date

Relationship to Child

The following individuals participated in the development of this individual plan (optional):

First and Last Name

Position / Role

Signature / Sign Off

First and Last Name

Position / Role

Signature / Sign Off