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 Info

Available Resources:

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