A Blank EH ISSP Form to Download, Be Completed and Submitted by the FRE

Imagine!’s Family Recruited Employee Services INDIVIDUAL SERVICE AND SUPPORT PLAN

NAME OF INDIVIDUAL: DATE OF BIRTH: DATE OF IP MEETING: DATE PLAN WRITTEN: STARTING DATE OF PLAN: END DATE OF PLAN:

IDENTIFIED OUTCOME FROM IP:

BASELINE/CURRENT SKILL LEVEL:

OBJECTIVE:

SUPPORTS NEEDED: (Describe any supports needed, in addition to those in the methodology, to make this ISSP successful.)

2009 Imagine! A copy of this plan needs to be submitted to the Case Manager within thirty (30) days of the individual’s staffing. METHODOLOGY:

TIME, DURATION, FREQUENCY OF TRAINING OR SUPPORT: No more than ______as written in the current service plan.

DATA COLLECTION: The Family Recruited Employee will submit time and contact notes through Dayforce as noted on the payroll schedule. Tracking will include the task, the number of times required in verbal prompting, the number of times hand over hand assistance is needed and the number of times they were able to perform tasks independently.

CRITERIA FOR EFFECTIVENESS:

2009 Imagine! A copy of this plan needs to be submitted to the Case Manager within thirty (30) days of the individual’s staffing. FREQUENCY OF REVIEW:

3 Month Review Date: Signature of Reviewing Staff: Is the plan still effective in addressing needs/outcome? Yes No Was it necessary to develop a new ISSP? Yes No If yes, were IDT members notified of the change? Yes No

NAME/TITLE OF THE PERSON(S) WHO DEVELOPED THIS ISSP:

NAME/TITLE OF THE PERSON(S) WHO WILL BE IMPLEMENTING THIS ISSP:

NAME/TITLE OF THE PERSON(S) WHO WILL MONITORING THIS ISSP:

STAFF/PROVIDER HAS BEEN TRAINED TO IMPLEMENT THIS ISSP: (supervisor date & initial):

DATE REVIEWED WITH PERSON RECEIVING SERVICES:

2009 Imagine! A copy of this plan needs to be submitted to the Case Manager within thirty (30) days of the individual’s staffing.