Individual Service Plan (Isp) For Individuals With Developmental Disabilities Living In The Community Template Page 6
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17ACTION PLAN FOR A DESIRED OUTCOME IN THE LIVE AREA
NOTE: USE A SEPARATE FORM FOR EACH OUTCOME
DATE OF ACTION PLAN:
TARGET DATE FOR COMPLETION/ACHIEVEMENT:
OUTCOME STATEMENT #
PERSONAL CHALLENGES AND OBSTACLES THAT NEED TO BE ADDRESSED IN ORDER TO ACHIEVE THIS DESIRED OUTCOME
(All listed challenges and obstacles must be addressed through action steps, teaching and support strategies and/or support plans)
SUPPORTS AND ACTION STEPS NEEDED TO REACH THE DESIRED OUTCOME
Identify the actions that the individual will take to reach the desired outcome, including things that the person wants to do and learn. In addition, include how natural, community, and specialized
supports and services will assist the individual in reaching his/her desired outcome. Include the use of existing assistive technology or environmental modifications used to achieve this outcome, as
appropriate (please refer to the AT Inventory for additional AT information.) Include the use of therapy (or other) evaluation or services needed to identify additional AT or environmental modifications
to achieve this outcome. Note: If the individual had a NM DDW Group A or B and will be transitioning out of their current residential model over the next year, consider incorporating skills to develop to
live more independently in the outcomes if related to their vision. Note: If Assistive Technology Service is being requested it must meet a desired outcome related to the person’s vision.
MEASUREMENT/CRITERIA
FREQUENCY
ACTION STEPS
STRATEGIES/WDSIs
RESPONSIBLE
TARGET
DOCUMENTATION AND REPORTING
HOW OFTEN, HOW
NEEDED
PARTY (IES)
DATE(S)
REQUIREMENTS
SKILLS TO LEARN AND TASKS TO DO
LONG
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
UNAVAILABLE SERVICES OR SUPPORTS
STEPS TO OBTAIN NEEDED SERVICES OR SUPPORTS
After implementing steps to obtain unavailable specialty services, if the services are still unavailable, complete a regional office intervention form and submit it to the local regional office.
NAME: ______ DOB: ____
EFFECTIVE DATE of ISP: ____
PAGE 6 OF 17
version 3/13
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