Person-Centered Support Plan - State of Florida
Person-Centered Support PlanAbout MeLast Name FORMTEXT ?????First Name FORMTEXT ?????Nickname FORMTEXT ?????Date Birth FORMTEXT ?????Medicaid ID FORMTEXT ?????PIN FORMTEXT ?????SSN FORMTEXT ?????Legal Status FORMTEXT ?????Where I Live FORMTEXT ?????The Address Where I Live FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Home Phone FORMTEXT ?????Work Phone FORMTEXT ?????Client Email Address FORMTEXT ?????My mail should be delivered to FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????My Legal Representative(s)Last Name FORMTEXT ?????First Name FORMTEXT ?????Guardian/Legal Representative Type FORMTEXT ?????Relationship FORMTEXT ?????Other FORMTEXT ?????Address FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Daytime Phone FORMTEXT ?????Nighttime Phone FORMTEXT ?????Cell Phone FORMTEXT ?????Email Address FORMTEXT ?????Last Name FORMTEXT ?????First Name FORMTEXT ?????Guardian/Legal Representative Type FORMTEXT ?????Relationship FORMTEXT ?????Other FORMTEXT ?????Address FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Daytime Phone FORMTEXT ?????Nighttime Phone FORMTEXT ?????Cell Phone FORMTEXT ?????Email Address FORMTEXT ?????My Waiver Support CoordinatorNameAgency (if applicable)EmailPhone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????My Family, Friends, and Support SystemNameRelationshipEmailPhone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other People Who Support Me or Work for MeNameRelationshipEmailPhone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Funding Sources for SupportsSupport NeedFunding Source FORMTEXT ????? FORMDROPDOWN If "Other" is selected, list the funding source. FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN If “Other” is selected, list the funding source. FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN If “Other” is selected, list the funding source. FORMTEXT ?????Who do I want to provide information for my support plan?Last NameFirst NameRelationshipPhoneInvite to Support Plan Meeting Y/N? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Y FORMCHECKBOX N FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Y FORMCHECKBOX N FORMCHECKBOX FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Y FORMCHECKBOX N FORMCHECKBOX My Life My current day-to-day life (Identify if I live alone or with others and my daily routines): FORMTEXT ?????My interests, talents, abilities, preferences, and skills: FORMTEXT ?????Things I would like to change: FORMTEXT ?????Things I want to stay the same: FORMTEXT ?????Important aspects from my personal history: FORMTEXT ?????How I make choices and decisions: FORMTEXT ?????My Personal and Future Plans: What I Want in the Next Few Years: FORMTEXT ?????Personal GoalsThe most important things I want to achieve the upcoming year. Identify goals and be as specific as possible. What service will help me? Paid or Non-Paid. If non-paid, provide name and relationship. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Services Needed for Health and SafetyInsert drop down list of services to address health/safety, i.e. nursing, personal supports, etc. Identified NeedService/SupportSource of SupportFunctional (May choose more than one) FORMCHECKBOX Vision FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Hearing FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Eating FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Ambulation FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Transfers FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Toileting FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Hygiene FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Dressing FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Communications FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Self-protection FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Ability to Evacuate (place of residence) FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ?????Identified NeedService/SupportSource of SupportBehavioral (May choose more than one.) FORMCHECKBOX Hurtful to Self/Self-injurious FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Aggressive/Hurtful to Others FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Destructive to Property FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Inappropriate Sexual Behavior FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Running Away FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Other Behaviors that May Result in Separation from Others. If “Other” is selected, please list the other behaviors. FORMTEXT ????? FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ?????Identified NeedService/SupportSource of SupportPhysical (May choose more than one) FORMCHECKBOX Injury to Person Caused by Self-injurious Behavior FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Injury to the Person Caused by Aggression to Others or Property FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Use of Mechanical Restraints or Protective Equipment for Maladaptive Behavior FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Use of Emergency Chemical Restraints FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Use of Psychotropic Medications FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Gastrointestinal Conditions (includes vomiting, reflux, heartburn, or ulcer) FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Seizures FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Antiepileptic Medication Use FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Skin Breakdown FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Bowel Function FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Nutrition FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Treatments FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ????? FORMCHECKBOX Assistance in Meeting Chronic Health Care Needs FORMDROPDOWN If "Other" is selected, list the source of support. FORMTEXT ?????What I Accomplished Last Year:My Accomplishments Last Year: FORMTEXT ?????Goals and progress made in the past year:Goals/Service NeedProgress on Goal FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Personal Rights: (not related to guardianship)I am aware of my personal rights and the Bill of Rights for Persons with Developmental Disabilities. Is there a right in which I would like to learn more? Choose Yes or No. FORMDROPDOWN Do I have restrictions on my rights? Choose Yes or No. FORMDROPDOWN This might include limited restrictions such as an unlocked bedroom door, limited food access, limited environmental access, etc.? If yes, complete the table.Right LimitedReasonWhat is being done to help me obtain my full rights?When it will the restriction be reviewed or terminated? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Safety Plan required and Attached (if applicable choose Yes or No.) FORMDROPDOWN My HealthImportant Information About My HealthHospitalizations in the past year Choose Yes or No.: FORMDROPDOWN If yes, why I was hospitalized? FORMTEXT ?????My Medication Information (Current as of date of support plan meeting)MedicationsDosage/FrequencyPurpose of MedicationSide Effects/Problems Evident FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Important Health History about My Family and Me: FORMTEXT ?????My critical health follow up areas and preventative health plan: FORMTEXT ?????Allergies: FORMTEXT ?????Health Care Contact Information: Please include all doctors you see, any therapists, and anyone you have designated to act as your decision maker in health related issues (health care surrogate)NameDate of Last VisitFindingsFollow Up Activities FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do I use any adaptive equipment, special equipment, glasses, hearing aids or need any adaptations made to my home? Choose Yes or No. FORMDROPDOWN If yes, please list below. FORMTEXT ?????Do I need any consumable supplies? Choose Yes or No. FORMDROPDOWN If yes, please list below. FORMTEXT ?????If There Is An EmergencyMy Emergency Contact Person:If there is an emergency, please call:Last NameFirst NamePhoneAddress FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Where will I go if I need to leave my home in the event of a disaster or emergency? FORMDROPDOWN If shelter, identify address: FORMTEXT ?????How will I evacuate? Choose an item.Who will take me, if I need help?Last NameFirst NamePhoneAddress FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do I have any medical equipment that would need to be powered or transported with me in the event of an emergency, evaluation, or power loss? FORMDROPDOWN If yes, please explain.Generator? FORMCHECKBOX Yes No FORMCHECKBOX Working Properly? FORMCHECKBOX Yes FORMCHECKBOX NoI am registered with a Local Emergency Management Team FORMDROPDOWN If yes, has my registration been updated or validated this year? FORMDROPDOWN Signature PageI have participated in the development of this plan. I have been informed of my due process rights under Florida Statutes 120 and acknowledge that I may appeal any portion of this plan. I understand that if my needs change and update to this plan may be needed. Supports should be identified according to my needs or the needs of my family, regardless of the availability of funding. Supports and services needed to meet my needs will be sought from my personal resources, community resources, and government resources. When government resources are necessary, they shall be provided based on the availability of funds. Consumer Signature FORMTEXT ?????Date FORMTEXT ?????Witness (if needed) FORMTEXT ?????Date FORMTEXT ?????Signature Legal Representative FORMTEXT ?????Date FORMTEXT ?????Waiver Support Coordinator Signature FORMTEXT ?????Date FORMTEXT ?????Date Copy of Plan Provided to Individual FORMTEXT ?????Date submitted to APD FORMTEXT ?????Signature of Support Plan Meeting Participants:SignatureRelationshipDateDate Support Plan Provided FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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