Ligas Transition Service Plan

Draft 07/24/12

INDIVIDUAL’S NAME:______

See Instructions for completion of the Transition Service Plan

Nameof Individual: ______

Address: ______

City: ______Zip: ______County: ______

Typeof Current Residence: ______

(Family Home, ICF/DD)

Current Daytime Activity: ______

Date of Birth: ___/___/____

Name ofGuardian: ______Type of Guardianship: ______

City / County of Guardian’s Residence: ______

Telephone Number: (___)______E-mail Address: ______

(SEE BELOW FOR CO-GUARDIANSHIP)

Name ofGuardian: ______Type of Guardianship:______

City / County of Guardian’s Residence: ______

Telephone Number: (___)______E-mail Address: ______

IF NO GUARDIAN, FAMILY CONTACTS: (release(s) on filefor family members, friends, etc)

Name: ______Relationship: ______

Telephone Number: (___)______E-mail Address: ______

Family Member City/ County Residence: ______

Current PAS/ISSA/ISC AGENCY: ______

Transition Plan Completed by (PAS/ISSA/ISC AGENT): ______Date: ______

Address: ______

Office Phone: (___)______Cell Phone(___)______Fax Number: (___)______

Email Address: ______

Note: Information must be typed, not hand-written.
Where does the individual want to live?
(City, county, or geographic region)
Preferred living arrangement?
(With family, alone in own apartment, in an apartment with roommates, in 24-hour supervised group home)
Is there anyone you would like to live with or near?
(Friendships)
Preference of day activity:
Personal Preferences:
(Likes, Dislikes, Interests, Current and Future Vision/Hopes, Religion, Cultural Customs )
Family Involvement / Relationships:
(Supportive Members, Guardian’s restrictions due to safety issues,Legal Restraining Order, Interpersonal relationships outside the family, and anyone the person may have issues with interacting.)
Communication Skills:
(Method of Communication, Equipment, Style of Understanding)
Mobility:
(Assistance needed in transferring, adaptive equipment needs, accessible living arrangement)
Personal Care:
(Meal Preparation, Eating, Hygiene, Bathing, Dressing, Household Chores, Repositioning, Level of Support)
Meal Time Assistance:
Special Dietary Needs:
Personal Decision Making:
(Ability to make decisions and the level of support needed in making these decisions)
Adaptive Equipment / Protective Equipment:
(Use of hearing aids, glasses, safety helmet, plate guard, Hoyer lift, etc.)
Behavior Support Needs:
(Supports needed for specific behaviors)
Medical / Physical Well-Being
(Healthcare supports needed)
Medications:
(Does the individual take his/her own medication without assistance? What assistance is the individual currently receiving?)
Legal Issues:
(Court involvement, Trust Fund Issue)
Other Risk Issues Not Identified Above:
(Community Access, Assessments)
Support Needs During Transition
(Day Visit, Overnight, Dinner Visit, Adjustment Period, Familiarization with staff)
Time Table
(Upon selection of provider, a schedule and transition process will be developed.

People who contributed to the Transition Service Plan:

Printed Name / Title

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