Individual Service Plan (Isp) For Individuals With Developmental Disabilities Living In The Community Template Page 4
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17HEALTH & SAFETY:
Provide summary information about significant health/medical/dental/behavioral/environmental concerns (past and present) and diagnosis(es) that have
implications for planning or impact on the individual’s health and safety, including what has been done to date to address these concerns. If the
person’s health or skills are regressing, include that information here.
Referral for new Assistive Technology
Environmental Modification Referral:
Intensive Medical Living Services Referral: (Prior authorization from DDSD required)
Preliminary Risk Screening (See Consultation notes)
Risk Management Plan
Supervision required: (The presumption is that individuals can be alone. Provide here specific timeframes, situations and environments where
supervision is required to ensure the individuals health and safety.)
Customized In-Home Services: clarify schedule and types of supports to be provided
Also, any issues not yet addressed should be included in Health and Safety Action Plan.
STRENGTHS, GIFTS, PREFERENCES, AND HOBBIES:
Describe what makes the individual unique. Provide detailed information about each of the sections below.
TALENTS, HOBBIES, AND INTERESTS:
STRENGTHS AND GIFTS:
PREFERENCES:
WHAT WORKS FOR AND MOTIVATES THE INDIVIDUAL:
VISION (WHAT I WANT IN MY FUTURE):
Describe what the individual desires for the future (i.e., dreams and aspirations without limits). Use relevant information from previous sections of the
narrative (e.g., desires regarding relationships and potential jobs and roles), and team input. Describe what the vision means to the person in terms of
how they define success. Analyze existing skills and resources available to achieve this vision and additional supports and skills needed, including
Assistive Technology if relevant.
LIVE:
WHAT DOES SUCCESSFUL ACHIEVEMENT OF THIS VISION LOOK LIKE?
WHICH OF THE INDIVIDUAL’S STRENGTHS/TALENTS AND/OR EXISTING SKILLS CONTRIBUTE TO ACHIEVEMENT OF THIS VISION?
WHAT PROGRESS HAS ALREADY BEEN MADE TOWARD THIS VISION? (include Assistive Technology the individual already uses)
WHAT STILL NEEDS TO OCCUR TO OVERCOME ANY BARRIERS AND ACCOMPLISH THIS VISION? (e.g. skill development needed, Assistive
Technology needed)
WORK/EDUCATION/VOLUNTEER:
WHAT DOES SUCCESSFUL ACHIEVEMENT OF THIS VISION LOOK LIKE?
WHICH OF THE INDIVIDUAL’S STRENGTHS/TALENTS AND/OR EXISTING SKILLS CONTRIBUTE TO ACHIEVEMENT OF THIS VISION?
WHAT PROGRESS HAS ALREADY BEEN MADE TOWARD THIS VISION? (include Assistive Technology the individual already uses)
WHAT STILL NEEDS TO OCCUR TO OVERCOME ANY BARRIERS AND ACCOMPLISH THIS VISION? (e.g. skill development needed, Assistive
Technology needed)
DEVELOP RELATIONSHIPS/ HAVE FUN:
WHAT DOES SUCCESSFUL ACHIEVEMENT OF THIS VISION LOOK LIKE?
WHICH OF THE INDIVIDUAL’S STRENGTHS/TALENTS AND/OR EXISTING SKILLS CONTRIBUTE TO ACHIEVEMENT OF THIS VISION?
WHAT PROGRESS HAS ALREADY BEEN MADE TOWARD THIS VISION? (include Assistive Technology the individual already uses)
WHAT STILL NEEDS TO OCCUR TO OVERCOME ANY BARRIERS AND ACCOMPLISH THIS VISION? (e.g. skill development needed, Assistive
Technology needed)
HEALTH AND/OR OTHER: (Note: This section is for a health related vision the individual has for themselves, such as “stop smoking,” “get in shape to
run a marathon” or “learn to take my medication” or a vision that does not fit under one of the other 3 areas. It is optional.)
WHAT DOES SUCCESSFUL ACHIEVEMENT OF THIS VISION LOOK LIKE?
WHICH OF THE INDIVIDUAL’S STRENGTHS/TALENTS AND/OR EXISTING SKILLS CONTRIBUTE TO ACHIEVEMENT OF THIS VISION?
NAME: ______ DOB: ____
EFFECTIVE DATE of ISP: ____
PAGE 4 OF 17
version 3/13
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