What is a Family Journal?

A family journal is an empowering and useful document which explains to your family in plain language, information they should know about in your absence. This file, journal or document states exactly what your wishes are. In regards of your child with autism should something happen to their parent or guardian.

Parents and guardians often worry about aging, illness and their own mortality. For who will love, care and advocate for our loved ones with autism when we are no longer able to care for them?

Planning ahead can give family members and future caregivers, easy access to vital information about your child with autism in one document, the family journal.

A journal should provide a brief description of your child, telling what he or she is like, what activities they enjoy or dislike to do, a list of favorite foods, rewards and motivators, how they spend their day, where they attend school, who their physicians are, healthcare information, and list the service providers for your child. A journal can also include both you and your child's future wishes as desired outcomes.

The Letter of Intent Worksheet or Individualized Service Plan (ISP) can help you create a family journal for your family member. An ISP is a document usually prepared by a service coordinator which provides a list of services, supports and guidance, funding and other information as needed to help the focus person live a fulfilled lifestyle and become more independent.

Below is a sample of an outdated family journal we created for our loved one using the same format and content as an ISP. We believe it is appropriate to share our document with other parents and caregivers so that a writer of their own family journal may see by example how even simple tips and observations can be quite useful when shared with others.

Sample Family Journal

Child's Name
Date of Birth
Social Security Number
Primary Health Insurance Number & Contact Information
Secondary Health Insurance Number (i.e. Medicaid Waiver) & Contact Information


Description / Appearance: [Child's name] is called “[Child]” at home. He is an African American male [age] with short cut dark brown hair and eyes. He is thin-framed at [height] and [weight]. [Child] is a bright and affectionate child who is generally well-behaved and follows rules. He is diagnosed primarily with Autism Spectrum Disorder. His medical conditions and illnesses are discussed below.

[Child] resides at home with his family. [Include names and ages of parents and siblings, pets if any.]

[Child] enjoys school. He has done well attending elementary school in district after 10-weeks in a more restrictive placement at [school] in [month, year]. [Child] attends district elementary school since [date]. [Child] strives and works hard to meet the demands of his [grade] curriculum. His current placement is ___:__ special education class with a 1:1 aide. He is mainstreamed for homeroom, art, music, library and physical education classes, as well as lunch, recess, special events and school trips. [Child] receives related services provided by the school district weekly: speech, occupational therapy, physical therapy, counseling and adaptive physical education.

After careful consideration and much discussion between parents and the school district, [Child] has been retained in [grade] this school year while awaiting placement at a NYS-approved private school. [Child]'s parents believe his current educational program does not adequately address his high level of need for a structured, therapeutic classroom with an emphasis on academics and enhancement of social skills. His parents visited several educational programs and believe the program and supports [Child] would need to succeed in [grade] at [school] is not currently in place.

For this reason, it has become necessary for [Child] to change placement for his educational program. [Child] will attend [school] in [city, state], starting in [month, year]. After screening, he has been found to be an appropriate candidate for their Option III (1:6:1) Social and Academic Learning Program. [Child] may attend sooner should a vacancy become available. [Child] will age-out of this placement at [age].

A future goal for [Child] is to be able to attend and receive benefit from an educational program that will meet his academic, social and vocational needs as he transitions into adolescence and young adulthood. [Child] wishes to remain living at home until adulthood.

[Child]’s parents are involved in developing his biomedical treatment plan and Individualized Education Plan (IEP). They advocate for [Child] and help troubleshoot along with the school district whenever problems or issues arise.

To address [Child]’s high level of need, his mother attended a one-week training, Son-Rise program to learn how to implement a child-centered social and language home-based program after school and on weekends. She plans to incorporate a sensory integration diet into this program to address his moderate to severe sensory integration deficits. Some sensory materials and equipment is needed in order to accomplish this.

[Child] is frequently sick and misses some school due to illness. He has chronic gastrointestinal symptoms and complaints since 15 months old of life. [Child] currently suffers with [state condition(s)], which is treated daily by [list of prescribed medications, nutritional and dietary supplements, dosage and how often taken.

On [date], [Child] had numerous tests [list tests] performed at [name of hospital or facility]. He has been examined and diagnosed by [physician] with [state any condition(s)].

On [date] [Child] had a diagnostic procedure performed at [name hospital or facility] by [name clinician] for [specify any condition(s)]. Approximately __ tissue sample biopsies were taken during the [specify producures(s)] for microscopic examination. His findings are impressive for their 'marked abnormalities.'

[Child] has recently been diagnosed with [specify any condition(s)]. This specific medical condition has recently been identified in over 200 children with autism and is currently under research. [Child] also has been diagnosed with [specify any condition(s)].

[Child] is prescribed [list medications] to treat this condition. His doctors also recommend dietary and nutritional supplements for [specify any condition(s)].

[Child] has been diagnosed with [specify any condition(s)], a sensitivity to sound in his right ear and borderline in his left ear. [specify treatment or intervention] has been recommended, which may be beneficial in correcting this condition. [Child] is apprehensive and frightened over certain humming sounds such as blow dryers and fans, like those found in public bathrooms.

[Child] no longer uses public restrooms outside of school. He may hold himself most of the day without relieving himself to avoid hearing hand-dry blowers and ventilation fans in most public restrooms. A portable male urinal is carried inside our vehicle in case of emergencies. This issue needs to be addressed. The family wishes to pursue ways to obtain funding for [specify treatment or intervention].

[Child] is a strong visual learner. He processes visual prompts easier than auditory communication. [Child] enjoys using the computer as assistive technology, enhancing his fine motor skills, communication, following simple directions and improves auditory processing deficits. The computer has been a strong learning tool for various educational, pre-vocational and social skills training. Family must assist [Child] in coping with the expectations of a normal day. This includes daily living routines, such as dressing, bathing, meal preparation and access to the community. To teach and ensure continued growth, an in-home Residential Habilitation (Res Hab) worker, [name Res Hab worker] will reinforce and assist [Child] in these areas.

[Child] has significant sensory integration deficits. He is unable to discriminate his presence in form and space. [Child] does not have a good sense of where his body is in space.

Whenever he becomes overwhelmed in wide-open space he may 'shut-down.' At these times, he is likely to stand still, eyes clinched shut, with his hands balled up at his sides. He may refuse to walk, move or let you lead him away. [Child] may become resistant should you try to remove him from the area during a 'meltdown.' It may be necessary to wait until after [child] regains some composure before attempting to leave. Administer his autism brushing protocol or read a short story to help him self-regulate. Important: Always travel with a sensory brush and at least two books.

[Child] presently prefers not to participate in any sports activity. As a result, [Child] has been unable to participate in any 'challenger' type sports activity. This stops him from participating socially and potentially making friends.

[Child] shows symptoms of moderate to severe sensory defensiveness in tactile and vestibular-proprioceptive sensory processing and auditory processing. [Child] is an active child yet shy and passive due to sensory issues. He is reluctant to try new things and needs someone to help him participate in activities. Physical Therapy was recommended by OT and a sensory evaluation to address gross motor deficits which began on or about [date].

[Child] frequently craves movement. He craves to climb and will climb on the back of furniture. He craves to swing so he swings from hanging flowerpots positioned over the furniture. [Child] is afraid of commonly used strap swings. He needs a sensory swing designed especially for individuals with disabilities, i.e. swing net or one with a backrest.

[Child] has hypotonia or weakness in his upper arms which causes difficulty with fine motor skills i.e. writing, cutting, and coloring. He has trouble snapping, manipulating buttons and zippers and is unable to dress himself independently. He has difficulty with gross motor skills such as sports and playground activities. [Child] shows poor sensory registration of movement. As a result his movements are stiff and awkward.

[Child] will not be hurried or rushed. In the morning he needs regular verbal prompts in 10-15 minute intervals in order to get ready for the day. He prefers to take his time and adjusts slowly to the expectations and activities in his surroundings. Due to sensory issues, he is a very selective eater and is resistant to eating more than a few select items from a self-limited menu.

[Child] prefers to keep busy but is not hyperactive. He is very particular about his toys. He lines them up and becomes very upset if anyone tries to move them or put them away. The toys need to stay precisely where he puts them until he becomes preoccupied with another activity or falls asleep. [Child] becomes upset whenever you clean up his room and put away his toys. [Child] loves roller coasters and trains, preferably diesel engines. He also is attracted to tractors, lawn mowers and the sound of any other loud, power-driven tool.

[Child] receives in-home Residential Habilitation to enhance and encourage his independence and daily living skills at home and in the community environment. [Child] receives in-home respite. After being unable to find a worker for a long period of time, his family now utilizes in-home Respite Services provided by [name of worker].

These supports give the family a break, and opportunity to attend support groups and/or leisure activities with the knowledge [Child] is being cared for appropriately. His family is most familiar with his medications, supplements, communication style, eating preferences, fears, perseverations and comfort supports.

[Child] has received adaptive equipment of a computer to facilitate his communication. An alarm system has also been installed at [Child]’s home to ensure his safety since he has a history of opening locked doors and windows and wandering out of the home, particularly at night.

[Child] has made significant progress in speech and language goals. He needs to address his sensory integration issues, which are not presently being adequately addressed. His social deficits can improve once he is better able to tolerate being in open spaces so he can attend social activities through residential habilitation. [Child] would also like to make friends.

Desired Outcomes: 1. [Child] wishes to live in a safe home with his family. To gain community experiences through activities and outings where he can meet new people and make friends.
2. [Child] will be able to continue to receive biomedical treatments and interventions he is currently making significant improvements from.
3. [Child] will be able to continue to receive continue dietary and nutritional supplements, as needed.
4. [Child]’s family will be able to obtain health care coverage or funding for these biomedical tratments, i.e. dietary and nutritional supplements.
5. [Child] will learn daily living skills so he is able to perform dressing, grooming and bathing independently.
6. [Child] will be successfully mainstreamed for academics as well as specials in school.
7. [Child] will attend and participate in special needs social and recreational opportunitites. Whenever appropriate, he will participate in mainstreamed socia1 activities.
8. [Child] will have play dates and develop friendships.
9. [Child] will learn to interact with friends in a socially correct manner.
10. [Child] will learn to ride a bike and roller-skate.
11. [Child] will acquire assistive technology to address his deficits and poor handwriting/drawing skills due to weak muscles in the upper extremities.
12. To minimize and reduce autistic characteristics and behaviors, i.e. non-compliance, meltdowns and tantrums.
13. To obtain information and education with parent/family training on specific topics related to autism, including but not limited to assessing progress of children with autism related to educational interventions; inclusion of autistic students; assistive technology in educational interventions; sensory integration dysfunction; sound-based therapies and auditory processing; motor development; intervention for problem behaviors; development in non-disabled children and children with autism; immunology; naturalizing language; use of communication and speech intervention; pharmacology; training model; brain plasticity; advocacy and legal issues; theory of mind; neuroimaging; peer related programming; toilet training; food selectivity; gluten/casein free diet; dietary and nutritional supplements; cost benefits of effective treatments; play and leisure skills; skill acquisition and behavior reduction; legislation, autism litigation; education policy and practices; environmental factors in autism; genetic research and funding.
14. Explore educational and medical interventions and treatments that may benefit [Child].
15. [Child] will be placed on waiting list for residential placement options as young adult, i.e. Assisted Living Apartment.
16. Family will arrange appropriate future planning for [Child].

Safeguards: [Child] practices evacuating his home during fire drills. There are smoke detectors in the hallways on every level of the home, a carbon monoxide detector in [Child]’s bedroom, as well as his parent’s bedroom. Fire extinguishers are located in the kitchen and garage. Upon evacuation the family will meet in the front driveway.

[Child] has a history of opening locked doors and windows and wandering away from the home or exiting the home unbeknownst to his family so an alarm system has been installed for safety. [Child] is not fully aware of potentially dangerous and threatening situations so 24-hour supervision, close monitoring and educating him in safety issues is necessary.

[Child] currently needs daily neutralization injections. He is presently taking prescription drugs: [list drugs], which are administered by his parents at home. [Child] also takes many supplements daily. Please see attached list and copy of prescriptions.

Practice telephone sessions to 911 in case of emergency. Conversation drills and drills to stay on phone line so the call can be traced. Practice safely crossing the street at home to board the school bus. Practice how to get off the bus safely and walk up the driveway to his home.

Natural Supports: Family [Child] has love, support and security of his family. He is the youngest of ____ children. He has ___ older siblings, [Names] [ages]. They are very supportive and understanding of him. [Child] has a young nephew, and is learning to socially adapt to him.

[Child]'s parents are very strong advocates on his behalf. They try to assist in meeting his high level of need to obtain services and resources, which may improve his health to enhance growth, academic and social success. Family attends many trainings to learn about autism, and network with other families and professionals.

Legal Guardians & Advocates: [Name parents, guardians] Alternate Legal Guardians: [Name alternate guardians]

Community Resources: (Associations and Community Center. Church or School Groups, Volunteer Services, Community Organizations, etc.)
Desired Outcome: To participate in community, school and family outings with his family, make friends and enjoy their company. [Child] enjoys bowling, computer and software programs to run and design roller coaster amusement parks. He enjoys eating out. His favorite fast foods are McDonald's and Wendy’s. The Ponderosa is his favorite buffet. He is able to order meals independently, and cannot give/receive correct change. [Child] enjoys going to the movies, Toys-R-Us, and the mall. He enjoys train rides. [Child] loves anything to do with roller coasters and trains and will gladly participate in any activity including his special interests. He also enjoys construction machinery, cars, and castles. [Child] enjoys learning through his computer and spends many recreational hours using it.

Plan of Service: (Includes Physician, Pharmacy, Laboratory, Hospital, Clinic, Dental, Physical Therapist, Occupational Therapist, Audiological, Personal Care Aid, Certified Home Health Care, Long Term Home Health Care, Durable Medical Equipment, Transportation, Day Treatment. Psychologist, Other.)

Provider Provider Agency, Street Address, City, State, Zip Code Phone No.

[Name] is the contact person at [name provider agency]. The Developmental Disabilities Service Office (DDSO) provides certain services for persons with autism. See the Services Guide for a detailed list of those services. For an updated Guide contact [name, contact info].

[Child]’s Medicaid Waiver is approved as of [date]. The waiver must be renewed annually via Dept. of Social Services to get his Medicaid card [secondary insurance] as part of the waiver. Recertification forms will come in the mail usually in May or June. All information related to his waiver is located in the file ‘Medicaid waiver.’ Presently [Child]’s waiver case is managed by [name of provider]. Should any questions or problems arise regarding [Child] or his waiver, do not hesitate to contact [name of service provider agency]. The contact person is [name] at:

Provider Provider Agency, Contact Person, Street Address City, State, Zip Code Phone No.

[Name Contact Person] is approachable and helpful. If you’re having a problem with anyone contact her for assistance.

Physicians Primary Care Physician, Street Adress City, State Zip Code
Phone No.

[Child] usually sees [name of clinician]. She’s nice and [Child] likes her. [Name of clinician] sees him only when absolutely necessary and for school or DDSO forms. Bring him in once a year for general visit. No VACCINES for school purposes – [Child] has religious exemption. [Amount of co-pay if any.]
Desired Outcome: Will provide routine medical care, as well as laboratory and diagnostic services as needed to allow [Child] to maintain good physical health and receive local treatment for illness with a local hospital affiliation.
Frequency: As needed Duration: On-going Effective Date:

Physician's Office, Street Adress City, State Zip Code
Phone No.

[Name clinician] specializes in [state specialty] and is also a DAN! Practitioner (Defeat Autism Now!). Currently, [name clinician] provides [list treatments, prescribed medications, any costs, when payment is due and acceptable forms of payment]. Important: Try to make appointments for [Child] one month prior to next, due to physician’s schedule. Ask for [name receptionist]. The others can be impatient and cross most times.
Frequency: As needed Duration: On-going Effective Date:

Physician's Office, Street Adress City, State Zip Code Phone No.

[Name clinician] is a [state specialty], referred to us by [name clinician], who performed [state any procedures] at [hospital or facility] on [date] Currently, [name clinician] provides [list treatments, prescribed medications, any costs, when payment is due and acceptable forms of payment]. Important: [name clinician] is only in the office on [list days]. Try to make appointments one month prior to the next.
Frequency: As needed Duration: On-going Effective Date: Desired Outcome: Will provide specialized [state specialty] medical treatments for [Child].

Physician's Office, Street Adress City, State Zip Code Phone No.

[Name clinician] is a [state specialty], referred to us by [name clinician], who performed [state any procedure(s)] at [hospital or facility] on [date] Currently, [name clinician] provides [list treatments, prescribed medications, any costs, when payment is due and acceptable forms of payment]. Does Not Accept both primary and [Child]’s secondary health insurance. See listing of compound pharmacy for prescriptions.
Frequency: As needed Duration: On-going Effective Date:
Desired Outcome: Will provide specialized biomedical treatments and monitor every four months.


Pharmacy Street Adress City, State Zip Code Phone No. Important: You may purchase allergy syringes for [Child] at the pharmacy using his Medicaid card. The allergy syringes are B-D Allergy Syringe, Single Use 1cc Syringe, 28 Gauge ½” (12.7mm) Needle, Product No. 305500. They come in a box of 100 syringes (10 packs – 10 each). The phone number to B-D is (800) 237-4554.
Please note: These needles are thin. This allows the injections to be painless vs. using a larger needle which is painful and can leave bruises. The syringes are kept in the pantry closet, second shelf, right-hand side. A large plastic container in the cabinet under the kitchen sink can be used to dispose of needles at home. You may also dispose the needles at a hospital or doctor's office. Do not hesitate to contact the pharmacy with disposal or any other questions.

[Compounding Pharmacy] Street Adress City, State Zip Code
Phone No.

[Child] is presently prescribed compounded vitamins and dietary supplements at [name facility]. He is taking [list compounded products, dosage and how often taken]. [Specify out-of-pocket costs and acceptable forms of payment.

Important: Pros & Cons [Pharmacy] – Accepts health insurances – no out-of-pocket costs. They do not have carry [name medication]. Find them not to be as professional as [Pharmacy]. Most often they owe you pills or must order your prescription(s). Long waiting times. Able to purchase B-D Allergy Syringes on Medicaid at [Pharmacy]. [Pharmacy] – Accepts health insurance – no out-of-pocket costs. Have compounding pharmacy that accepts Medicaid. However, will not accept [Child]’s compounding prescriptions. Still investigating this matter.
Desired Outcome: Will fill prescriptions and OTC medication and supplies as needed and ordered by physicians. Frequency: As needed Duration: On-going Effective Date:


Name of Lab Street Adress City, State Zip Code Phone No.

[Child] likes [name of two lab technicians] to draw blood. Request them whenever available. Accepts both health insurances – no out-of-pocket costs.

Hospital Lab Street Address City, State ZipCode Phone No. Fax No.

Accepts both health insurances – no out-of-pocket costs. May need follow-up call to remind them to fax results to physician. Desired Outcome: Will provide laboratory and diagnostic services as needed and ordered by [Child]’s physicians.
Frequency: As needed Duration: On-going Effective Date:

Specialty Lab Street Address City, State ZipCode Phone No. Account #
RX#s Website: Email:

[Specialized lab] does [Child]’s urine peptides test (gluten/casein peptide levls) and stool tests. Hair tests at [name of Specialized lab]. Use for specialized tests (DAN!, Pfeiffer). See clear binder (medical book) for test results. See file folder 'Medical Tests' for invoices. Do not hesitate to contact any specialty lab for questions or concerns. Very helpful!
Desired Outcome: Will provide specialized laboratory and diagnostic services as needed and ordered by physicians. Frequency: As needed Duration: On-going Effective Date:

Specialty Lab Street Address City, State ZipCode Phone No. Account #
RX#s Website: Email:

Fine lab. Use whenever [Child’s] doctor won’t prescribe a medical test you believe is necessary. Their own doctors prescribe tests and give excellent written reports. Reasonable prices. Accepts personal checks, major credit cards. Also use for certain autism related tests (DAN!, Pfeiffer). See clear binder (medical book) for test results. See file cabinet under “Medical Tests” for invoices.
Desired Outcome: Will provide laboratory and diagnostic services as needed and ordered by [Child]’s parents and/or physicians.
Frequency: As needed Duration: On-going Effective Date:


Name Physician Street Address City, State ZipCode Phone No. Fax No.

The National Institutes of Health created several Centers of Excellence for Autism Treatment. One center is the Autism Treatment Center at UMDNJ. [Name Physician] accepts both forms of health insurance. For updated list of centers do Google search.

Name Physician Street Address City, State ZipCode Phone No.

[Name] is a good neurologist to use for latest treatments, conventional and alternative medicine. Performed [state procedure] on [date]. [State results and list of medications, if any]. Able to use Medicaid card to pay co-pay. No out-of-pocket costs for visits.

Name Physician Street Address City, State ZipCode Phone No.

[Name Physician] is a very good local neurologist who diagnosed [Child] with [list diagnosis]. He is a really good neurologist for help in developing an educational program. [Child] has not seen him recently since he does not accept our health insurance or Medicaid.
Desired Outcome: Will provide neurological services again should he accept our health insurance.
Frequency: As needed Duration: On-going Effective Date:

[Child] was diagnosed with [list diagnosis] by [Name Physician] at [hospital] on [date]. See medical report in clear binder (medical book). There is no reason for [Child] to ever see this doctor again. Not helpful after diagnosis.


Name Psychologist, Street Address City, State ZipCode Phone No.

[Psychologist] is presently testing [Child] to help develop an appropriate educational program for him. He began seeing him on [date]. [Name physician] makes his own appointments. Call to schedule or cancel an appointment directly with him. [Name physician] does not take our health insurance. Presently, the school district is paying for neuro-psychological tests and reports, as part of [Child’s] Independent Education Evaluation.

Dental Care:

Name of Dentist Street Address City, State ZipCode Phone No.

[Dentist] performed oral surgery at [name hospital] on [date]. He accepts Medicaid. Dentist treats patients with developmental disabilities.

Name Dentist Street Address City, State ZipCode Phone No.

New local dentist provides quality, respectful dental services to persons with developmental disabilities. Accepts our health insurance and Medicaid.
Desired Outcome: This dentist will provide [Child] with annual dental examinations, quarterly cleaning, and preventive, restorative services. Very nice and patient.
Important:Make first morning appointments to avoid very long waiting time.
Frequency: As needed Duration: On-going Effective Date:

Related Services:

Child's School, Street Address City, State Zip Code Phone No.

Name Director of Pupil Personnel
Name Supervisor of Special Education

Important: It is very important to develop a respectful, working relationship with the school district. Always be in control of your emotions at an IEP meeting. Should you become upset, immediately excuse yourself, go to the restroom and regroup. If you are unable to continue or unsure that you are, go back into the meeting. Tell them you’re ill and need to reschedule the meeting for another day.
Make every effort to have an educational advocate attend IEP meetings for [Child]. Ask the advocate to take notes and ask for an immediate copy of them to verify what transpires at meetings. Should there not be an advocate available to attend a meeting bring at least one other person who knows and cares about [Child]. Someone must take good notes. Reschedule an IEP meeting so you are not alone when you attend the meeting. Or tell district before the meeting you will tape record.
Begin to introduce [Child] to attend his IEP meetings by having him come into the meeting room 15 minutes before it ends. [Child] needs to learn to self-advocate over time and become comfortable in a room with many people discussing his needs, education and vocational programs.
Desired Outcome: To provide related services, assistive technology, computer software, modified seating and slantboard.

Frequency: 1x Group, 30 minutes; 1x week Individual, 30 mins.
Effective Date:

Physical Therapy: Frequency: 2x week Individual, 30 mins
Effective Date:

Speech Services Frequency: 3x week Group; 30 mins; 2x week Individual
30 mins
Effective Date:
Desired Outcome: See attached IEP for specific goals and details.

Speech, Occupational Therapy and Physical Therapy, including
Swim Therapy


Facility Name, Therapist(s) Street Address City, State ZipCode Phone No.

Accepts both Medicaid and primary health insurance. [Child] may attend during summer sessions should his summer program with the school district ever not provide adequate services. Ask for [name therapist] for speech whenever available. [Child] really likes her.

Case Management/Service Coordination


Name Facility Name Therapist Street Address City, State ZipCode Phone No.

Child's service coordinator is [name] However, [Child] is currently enrolled in a Plan of Service, which means the service coordinator only updates his ISP every six months. Should anything happen to Mother contact the agency and request immediate service coordination. You have the right -- and feel free to change service coordinators and/or agencies to provide any service. It is more harmful to remain in an unsatisfactory relationship than it is to change over to someone else or another agency. This is commonplace and is handled quickly by the DDSO.
Desired Outcome: To assist as necessary in gaining access to needed Medicaid Waiver and other state plan services as well as medical, social, educational, and other services. To provide referral and linkage to services, funding and information to help [Child] live a fulfilled lifestyle while providing support and guidance as needed to become more independent.
Frequency: Minimum monthly Duration: On-going Effective Date:

Federal or State Agency Funded Resources Provider: School [Name Family Service Coordinator or Social Worker]
Street Address City, State ZipCode Phone No.

Desired Outcome: To provide [Child] with transportation with a 1:1 bus aide from an appropriate school and educational program which includes lesson plans broken down into smaller components; facilitate positive interactions with peers; teach pre/vocational skills to prepare him for employment and daily functional living skills. Provide [Child] with a free and appropriate education so he is able to pursue his goals and dreams as an adult and live independently.
See attached IEP in clear binder (education book) for specific goals and details.
Frequency/Duration: Monday-Friday, 9:00am to 3:30pm Effective Date:

Consideration for Financial Reimbursement


Name Agency Contact Person Street Address City, State Zip Code Phone No.

Desired Outcome: Non-profit agency referred to family for council member consideration to provide family with subsidy or reimbursement for goods, services, and advocacy as a last resort when funding allows and counsel permits.
Frequency: As needed. Duration: On-going Efffective Date:

HCBS Waiver Services: (Including Case Management, Residential Habilitation, Day Habilitation, Provocational, Supported Employment, Respite, Environmental Modifications, Adaptive Devices)

Assistive Techno1ogy/Home Environmental Modifications:


Company Name Street Address City, State 10940 Phone No.

Desired Outcome: To provide an alarm system to notify family whenever [Child] leaves the home. Frequency/Duration: Continuously Effective Date:

Computer Provider: Company Name Street Address City, State Phone No.
Customer #______
Technical Support Information:
Warranty Information:
Desired Outcome: Provide computer to facilitate communication, provide learning opportunities by reinforcement and repetition, address auditory processing deficit, visual stimulation and fine motor coordination i.e. ability to write and autism research.



Name Agency Contact Person Street Address City, State Zip Code Phone No.

Desired Outcome: To provide family with opportunity for leisure and social activities. To provide quality child care for [Child] in case of emergency.
Frequency: On-going Duration:___ hours month Effective Date:

Residential Habilitation:


Name Agency Contact Person Street Address City, State Zip Code Phone No.

Desired Outcome: To provide [Child] a mentor and facilitator to help him meet his desired goals (see attached). [Name] is currently [Child]'s Res Hab worker.
Frequency: ___ hours weekly Duration: On-going Effective Date:

[Child]’s Desires:

Parent Wishes:

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