*DT& H Program Site
Apple Valley
Brooklyn Park
Eagan
Oakdale
Shoreview
St. Paul
*Please specify
Intake Meeting
45 Day Review
Quarterly Review
Semi-Annual Review
Annual Review
Discharge/Other
LIFE PLAN
Name:
Date:
Persons Responsible for Development of Plan:
Persons Responsible for Implementation of Plan:
Date of Assessment:
The following are strength areas:
The following are growth areas:
Special Considerations/Procedures:
*Attached to this IHP/IPP you will find: BWAP 2 SCORES and the Proposed/Current goals
Assistive Technology with Regard to Program Plan
Communication
Transition Plan (into program, school, work, etc.)
1. Does the IDT Advocate agree that the Autism Program at Midwest Special Services, Inc. is
appropriate for
?
2. Is further education in
3. Is supported employment in
4.
’s future plans?
’s future plans?
’s goal for housing is:
Social Skills
1
Revised: May 2015
Cultural/Spiritual Considerations/Issues with regard to Program Plan
Individual Benefits Planning
Changes in regulations:
Changes in person’s life:
Proposed Goal Areas
Not all goal areas may be appropriate for all participants.
1. Sensory:
2. Independent Living:
3. Leisure/Recreational:
4. Communication:
5. Vocational:
6. Domestic:
7. Physical:
Priorities/Expectations
Worker Input/Comments
To the best of his/her ability,
was able to participate in his/her meeting and added the following:
Additional Comments
Long-Term Planning Considerations
’s future, the following checklist was developed to assist the IDT in offering the
appropriate level of assistance to
in the following areas.
Please indicate the level of assistance needed for each area by placing an “X’ in the appropriate column.
Full
Some
No
Assistance Assistance Assistance
Needed
Needed
Needed
N/A
Comments
As part of planning for
Budgeting
Meal Planning
Personal Cares
Housekeeping
2
Revised: May 2015
Long-Term Planning Considerations
’s future, the following checklist was developed to assist the IDT in offering the
appropriate level of assistance to
in the following areas.
Please indicate the level of assistance needed for each area by placing an “X’ in the appropriate column.
Full
Some
No
Assistance Assistance Assistance
Needed
Needed
Needed
N/A
Comments
As part of planning for
Financial Services
Medical/Dental
Needs
Community
Resources
Educational
Opportunities
Community
Transportation
Safety Skills
Living
Arrangements
Family Supports
Benefits Planning
Advocacy
Additional Comments:
Reasonable Accommodations Needed
*Discuss and update annually. Only comment on areas requiring accommodations.
Environment:
Mobility:
Communication:
Education:
ADL (Activities of
Daily Living):
Employment:
Sensory:
Transportation:
Recreation/Leisure
Other:
3
Revised: May 2015
Personal Circle of Advocates
The following is a list of individuals who can and will advocate on behalf of and/or in cooperation with
to ensure that his/her Life Plan is being followed as prescribed:
Signature Page
The following IDT members were present and participated in the development of the vocational goals and
objectives for
. Date:
Signature*
Relationship/Title
INVITED BUT NOT IN ATTENDANCE:
*Along with attending the meeting, I believe the Life Plan and attached goals are appropriate and relevant to
’s current life situations.
Guardian Signature
Date
Verbal
Interpreter (Name of Interpreter:
This information was communicated to me by:
)
Written format
Other (describe)
Report submitted by:
Name/Title
Date
Copies sent to IDT members on:
Date of next review:
4
Revised: May 2015