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Individual Plan
 
Individual Plan Info & Header
Provider Name
TUMNUS PETER
Provider ID
123456
    
 
Individual Plan Number
01-072810-1-9-1
Individual Plan Start Date
07282010
    
 
Member Name
SUSAN ASLAN
Member ID
987654321
Date of Birth
12/02/1979
Address
123 MAIN ST
BALTO,  MD  12345
Phone
--
County
  
 
 

Service Plan Goals
Long Term Goals:
Strengths
Consumer/Caregiver Expectations and Responsibilities
Goal 1
 
Long Term Goal:
Status of Goal:
Revised
Responsible Staff:
Short term goal 1
 
Short Term Goal Target Date:
07232010
Status of Goal:
Revised
 
 
Short Term Goals:
Interventions:
Update Progress
Short term goal 2
 
Short Term Goal Target Date:
Status of Goal:
 
 
Short Term Goals:
Interventions:
Update Progress
Short term goal 3
 
Short Term Goal Target Date:
Status of Goal:
 
 
Short Term Goals:
Interventions:
Update Progress
                   
Consumer Involved in Plan?
  
Family/Caregiver/Guardian Involved in Plan and Interventions?
    

Was Consumer offered a copy of the plan?

  

  
  
Individual's Hope for Recovery/Resiliency (in consumer's own words)
Discharge Plan
(Include the goals that the consumer needs to accomplish in order for the transition/discharge to occur, the supports needed at time of discharge/transition, and an estimated timeframe within which the transition/discharge will realistically occur).
Expected Discharge Date
Responsible Staff:
 1. 
 2. 
 3. 
 4. 
 
 
Signature:
Consumer:                             ________________________________________________ Date:  ____________________
 
Parent/Guardian:                  ________________________________________________ Date:  ____________________
 
Provider 1 and Credentials:  ________________________________________________ Date:  ____________________
 
Provider 2 and Credentials:  ________________________________________________ Date:  ____________________
 
Support - Other1:                 ________________________________________________ Date:  ____________________
 
Support - Other2:                 ________________________________________________ Date:  ____________________
 
Other - Relationship to the Consumer: ________________________________________________ Date:  ____________________
 
Other - Relationship to the Consumer: ________________________________________________ Date:  ____________________