Name: DMH ID:
Consumer Name
Date of ISP Meeting:
ISP Implementation Date:
State ID:
DOB:
DEMOGRAPHICS
Waivered: Type:
Regional Office/SB40:
Service Coordinator:
Primary Language of Individual:
______
Name: Date of Implementation:
I.D.#: ISP Meeting Date:
______
DIAGNOSIS
Axis I:
Axis II:
Axis III:
______
CONSUMER INFORMATION
Medicare #: Medicaid #:
Social Security #: Active Medicaid:
Dental Insurance:
______
CONTACTS
Consumer Phone #: County:
Consumer Address:
Contact/Family:
Contact/Family Phone #:
Contact/Family Address:
Guardian: County:
Guardian Phone #:
Guardian Address:
Conservator:
Conservator Phone#:
Conservator Address:
Daily Life:
A. Home:
Ø Hygiene
Ø Home Maintenance
Ø Leisure activities
B. School
C. Employment
D. Service and Supports:
Ø Support Preferences
Ø Behavior Supports
Ø Current Supports
Ø Projected Supports
E. Financial
Community Living:
A. Living arrangement
B. Transportation
C. Community Access
D. Adaptations/Modifications
Social and Spirituality:
A. Communication
Ø Verbal
Ø Nonverbal
Ø Behavioral
B. Natural Supports
C. Strengths
D. Community Connections
Safety and Security:
A. Emergency Planning
B. Legal (Guardianship/alternatives, Voter Registration)
C. Client Rights
Ø Restrictions
Ø Rights Restoration
D. Level of Support
Healthy Living:
A. Medical
B. Physical
C. Nutrition
D. Behavioral Health
Advocacy and Family Support:
A. Individual Goals, Dreams, Hopes, and Wants
Ø Past
Ø Future
B. Family/Guardian Goals/Vision
ACTION PLAN
The outcomes have been prioritized by the individual and/or family or guardian.
Outcome: A.
What Is Going To Be Done:
Who:
Start Date:
Stop Date:
Training Plan Needed from Provider: Yes/No/NA
How we will know the outcome has been reached:
Outcome: B.
What Is Going To Be Done:
Who:
Start Date:
Stop Date:
Training Plan Needed from Provider: Yes/No/NA
How we will know the outcome has been reached:
COMMENTS
County Connections Notice of Privacy Practices was given to and reviewed with consumer.
Self Directed services were discussed with consumer.
Consumer attended the annual meeting.
I allow my service coordinator to correspond with me and/or provider agencies by e-mail /Yes No
· I understand that there are inherent risks associated with electronic communications and that the security of my private information cannot be guaranteed.
RESOURCES
Current Resources:
OTHER AGENCIES PROVIDING SERVICES / INITIATION DATE / REASON FOR SERVICES / FUNDING SOURCE / Contact InfoAvailable Resources:
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