Individual Service Plan (Isp) For Individuals With Developmental Disabilities Living In The Community Template Page 17
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17ISP MEETING PARTICIPANTS
DATE OF MEETING:
By signing below, I am indicating that I participated in the development of this individual service plan and will be responsible for implementing relevant
portions of the plan. Individuals who participated in a manner other than attendance at the meeting must be listed by the case manager with the
method of participation stated in the signature column.
MEETING PARTICIPANTS
SIGNATURE
CONTACT INFORMATION
(PRINT NAME AND AGENCY)
INDIVIDUAL:
PHONE:
FAX:
E-MAIL:
GUARDIAN:
PHONE:
FAX:
E-MAIL:
FAMILY (SPECIFY RELATIONSHIP):
PHONE:
FAX:
E-MAIL:
FRIENDS/ADVOCATES:
PHONE:
FAX:
E-MAIL:
CASE MANAGER (SPECIFY AGENCY):
PHONE:
FAX:
E-MAIL:
CONTACT INFO:
RESIDENTIAL STAFF (SPECIFY AGENCY):
SERVICE COORDINATOR:
CONTACT INFO:
DIRECT STAFF:
CONTACT INFO:
DAY SERVICES STAFF (SPECIFY AGENCY):
CONTACT INFO:
SERVICE COORDINATOR:
CONTACT INFO:
DIRECT STAFF:
CONTACT INFO:
DAY SERVICES STAFF (SPECIFY AGENCY):
CONTACT INFO:
SERVICE COORDINATOR:
CONTACT INFO:
DIRECT STAFF:
CONTACT INFO:
OTHER (SPECIFY RELATIONSHIP AND AGENCY):
PHONE:
FAX:
E-MAIL:
OTHER (SPECIFY RELATIONSHIP AND AGENCY):
PHONE:
FAX:
E-MAIL:
OTHER (SPECIFY RELATIONSHIP AND AGENCY):
PHONE:
FAX:
E-MAIL:
OTHER (SPECIFY RELATIONSHIP AND AGENCY):
PHONE:
FAX:
E-MAIL:
OTHER (SPECIFY RELATIONSHIP AND AGENCY):
PHONE:
FAX:
E-MAIL:
NAME: ______ DOB: ____
EFFECTIVE DATE of ISP: ____
PAGE 17 OF 17
version 3/13
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