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DISTRICT 19 COMMUNITY SERVICES BOARDINDIVIDUALIZED SERVICES PLANPROGRAM NAME: Date: Primary Service Provider: (Usually the Case Manager) Program Service Provider: (Name)Quarterly Review Dates: 1st __________ 2nd __________ 3rd __________ 4th __________Estimated duration of service plan: Date and name of supporting assessment documents:Consumer strengths, preferences, and limitations: (i.e., social supports, compliance with services or medications, etc.)Role of other service providers in implementing the plan and meeting overall consumer goals: (i.e., other D19 programs, PCP, other agencies, private providers, etc.)List employees responsible for coordination and integration of services, including other agencies: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Attach/include: Behavioral treatment plan, if applicableCommunication plan, if applicable (i.e. language barriers, non-verbal, speech impediment, etc.)Individualized discharge plan: (Describe transition to other appropriate services) Indicate whether discharge is expected during this ISP cycle; include aftercare and follow-up referrals. Include a general plan if discharge is not expected during this cycle.)Does the consumer desire a Wellness Recovery Action Plan that addresses crisis self-management strategies? Yes/NoDoes the consumer have an Advanced Directives? Yes / No (If “yes, attach to the current Face Sheet.)12VAC35-105-660. Individualized Services Plan (ISP).D. The initial ISP and the comprehensive ISP shall be developed based on the respective assessment with the participation and informed choice of the individual receiving services. To ensure the individual's participation and informed choice, the provider shall explain to the individual or his authorized representative, as applicable, in a reasonable and comprehensible manner, the proposed services to be delivered, alternative services that might be advantageous for the individual, and accompanying risks or benefits. The provider shall clearly document that this information was explained to the individual or his authorized representative and the reasons the individual or his authorized representative chose the option included in the ISP.As per this regulation, I hereby attest with my signature that I have participated in the development/revision of my plan and I agree with its goals. I know about my choices along with the benefits and risk that may accompany them. I also agree to receive services from this program and the criteria for discharge from the program have been explained to me.ConsumerDateLegally Authorized Representative (if applicable)DateSignature and relationship of other participants in service planning: SignatureRelationshipDateSignatureRelationshipDateSignatureRelationshipDateSignatureRelationshipDateProgram Service Provider (if applicable)DatePrimary Service Provider (if applicable)DatePsychiatrist (if applicable)DateSupervisor, Title (optional if needed)DateAll programs must have at minimum three (3) “Problem” areas addressed on their ISPs, (1) Psychiatric Emergency/Crisis Plan (2) Medical and (3) the Specific Program problems, goals and objectives.AEB = As Evidenced ByProblem #1: Psychiatric Emergency/Crisis PlanConsumer’s psychiatric symptoms may deteriorate which may prompt crisis intervention and/or hospitalization As Evidenced By: Goal: DateMeasurable ObjectivesTarDateAchDatePlease describe below the intervention strategies, frequency of the contacts, and the provider(s) involved.1. Strategy/Intervention:Frequency:2.Strategy/Intervention:Frequency:3.Strategy/Intervention:Frequency:4.Strategy/Intervention:Frequency:Problem # 2. Medical_Consumer does have chronic health & medical issues.AEBConsumer does not have chronic health & medical issues.Goal: DateMeasurable ObjectivesTar DateAchDatePlease describe below the intervention strategies, frequency of the contacts, and the provider(s) involved.Consumer will:1. Strategy/Intervention:Frequency:2.Strategy/Intervention:Frequency:3.Strategy/Intervention:Frequency:4.Strategy/Intervention:Frequency:Problem : # ___ _________________AEBGoal: DateMeasurable ObjectivesTar DateAchDatePlease describe below the intervention strategies, frequency of the contacts, and the provider(s) involved.Consumer will:1. Strategy/Intervention:Frequency:2.Strategy/Intervention:Frequency:3.Strategy/Intervention:Frequency:4.Strategy/Intervention:Frequency:Problem: # ___ ______________AEBGoal: DateMeasurable ObjectivesTarDateAchDatePlease describe below the intervention strategies, frequency of the contacts, and the provider(s) involved.Consumer will:1. Strategy/Intervention:Frequency:2.Strategy/Intervention:Frequency:3.Strategy/Intervention:Frequency:4.Strategy/Intervention:Frequency:Problem: # ___ ____________AEBGoal: DateMeasurable ObjectivesTarDateAchDatePlease describe below the intervention strategies, frequency of the contacts, and the provider(s) involved.Consumer will:1. Strategy/Intervention:Frequency:2.Strategy/Intervention:Frequency:3.Strategy/Intervention:Frequency:4.Strategy/Intervention:Frequency:Problem # ___ __________AEBGoal:DateMeasurable ObjectivesTarDateAchDatePlease describe below the intervention strategies, frequency of the contacts, and the provider(s) involved.1. Strategy/Intervention:Frequency:2.Strategy/Intervention:Frequency:3.Strategy/Intervention:Frequency:4.Strategy/Intervention:Frequency:Problem # ___ __________AEBGoal:DateMeasurable ObjectivesTarDateAchDatePlease describe below the intervention strategies, frequency of the contacts, and the provider(s) involved.1. Strategy/Intervention:Frequency:2.Strategy/Intervention:Frequency:3.Strategy/Intervention:Frequency:4.Strategy/Intervention:Frequency:Problem # ___ ______________AEBGoal: DateMeasurable ObjectivesTarDateAchDatePlease describe below the intervention strategies, frequency of the contacts, and the provider(s) involved.Consumer will:1. Strategy/Intervention:Frequency:2.Strategy/Intervention:Frequency:3.Strategy/Intervention:Frequency:4.Strategy/Intervention:Frequency: ................
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