INDIVIDUAL: _____________________________DATE OF BIRTH
Information Name: ___________________________________________________ Date of Birth: ____________Gender: M F Address: ____________________________________________________________City: __________________________ Zip: __________________ County: ________________ Phone: ________________________ E-Mail:__________________________________________ Profile and Desired Outcomes developed by:Current PAS/ISC/ISSA Agency: ____________________________________________________________PAS/ISC/ISSA Representative: _______________________________ Date Completed:_____________Address: ______________________________________________________Office Phone: (___)_____________ Cell Phone(___)________________ Fax Number: (___)_____________Email Address: _________________________________________Inventory of Current Enrollments:Residential: _____Home-Based Services ______CILA _____ICF/DD 9 or more _____ICF/DD 8 or less _____CLF _____Other DD-funded _____No DD-funded residential programDay Services/Work: _____DT _____Regular work (38U) _____Adult Day Care _____At-Home Day Program _____DD/SEP _____DRS/SEP ______Other DD-funded ______No DD-funded day servicesOther: _____Behavior Supports _____Full time Competitive Employment _____Part time Competitive Employment ______Other:_____________________________________________________________________________________Personal Preferences and Priorities 1. What do others admire and appreciate about the person? (What is the person’s gift or capability that connects them to others?) 2. Who are the people most important in this person’s life? (What are their names and their relationship to this individual?) 3. Personal Preferences/What is most important to the person:(things to do or have/rituals or routines; rhythm or pace of day/life; people to spend time with; vision/hopes, religion, cultural customs)4. What is the person interested in learning or doing? (What types of interests or activities would this person like to spend their time on related to advancing their skills or learning to do?) 5. Where does the individual want to live? (City, county, or geographic region) 6. Preferred living arrangement? (With family, own apartment, in an apartment with roommates, host family, in 24-hour supervised group home.)7. How would you describe people the individual wants to live with or near? (Friendships) 8.Type of work/work training he/she is interested in trying: If no paid work, then what could this person do during the time he/she is not at home? 9. Family Involvement / Relationships:(Supportive members, who is involved; important friendships that need to be supported; who does the person want to have involved) munity Opportunities(What types of community activities is this person most interested in participating?)Summary of Abilities and Contributions to Community Life. Identification of Needs for Support:1. Communication Skills:(How he/she communicates best; method of communication, equipment, style of understanding; support needed so that others successfully understand and communicate with the person directly.)2. Mobility:(How the person is able to get around; physical skills and abilities; support needed in any area, including walking, standing, transferring. Include any adaptive equipment and/or the type of accessibility supports needed.)3. Daily routines and personal care:(His/her ability to participate in and carry out tasks related to personal hygiene, bathing, dressing, household chores such as laundry and cleaning, etc. Describe the type of support needed to be successful in any of these areas.)4. Finances: (His /her ability related to math skills, personal budgeting, banking, and managing money. Indicate the type of support that is needed to assure the person is successful in this area.) 5. Meal Time Assistance: (skill and ability related to meal preparation, eating, swallowing; identify any support needed, any special dietary needs and known food allergies.) 6. Personal Decision Making:(Description of the type of support needed, if any.)Health, Well Being and Safety 1. Adaptive Equipment / Protective Equipment Used: (Use of hearing aids, glasses, safety helmet, plate guard, Hoyer lift, etc.)2. Medical / Physical Well-Being: (Healthcare supports needed, known allergies) 3. Medication Use: (Does the individual take his/her own medication without assistance? What assistance is the individual currently receiving?)4. Public Safety: (What are the person’s skills related to identifying dangerous situations, strangers, poisonous or non-edible materials, traffic skills. What support is needed in any of these areas?)5. Legal Issues: (Justice system involvement, trust fund Issue, court orders, e.g. orders of protection, probation, incarceration.)6. Behavioral Health Needs: (Supports needed for mental health, addiction, and/or specific behaviors)7.Other known issues that pose a risk to health or safety, not Identified above:Primary Contact: (release(s) on file for family members, friends, etc)Name: ___________________________________________Relationship: _______________________Contact Address: ______________________________________________City: __________________________ Zip: __________________ County: ________________Phone: ________________________ E-Mail:__________________________________________Does the individual have a guardian? (circle one) YES NOName of Guardian: ____________________________________ Type of Guardianship: ________________Guardian Address:__________________________________________________________________________City: __________________________ Zip: __________________ County: ________________Phone: ________________________ E-Mail:__________________________________________Name of Guardian: ____________________________________ Type of Guardianship: _________________Guardian Address:__________________________________________________________________________City: __________________________ Zip: __________________ County: ________________Phone: ________________________ E-Mail:__________________________________________People who contributed to the development of this Profile and Desired Outcomes document:Printed NameSignatureTitleIndividual receiving servicesGuardian (if applicable)PAS/ISC/ISSA representative This page serves as placeholder. In its place within the final document there will be a form to outline the action plan to choose and transition to selected service providers. The final form may be completed as part of the same meeting in which the Profile and Desired Outcomes document is completed or may be done at a separate time. If completed at a different time, a separate signature block of those contributing to the action plan will be included.The Profile and Desired Outcomes, along with the action plan, will be completed at the time of enrollment and annually, thereafter. ................
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