THIS IS MY PLAN: Name

My Dreams and Desires:

My Circle of Support:

What I want my circle of support to know is:

What worked for me last year:

What did not work for me:

My desire outcome/outcomes for this year:

What I want people to know about me is:

How to communicate with me:
My learning abilities or style:
How to get to know and understand me
My fear and challenges:
What are my hobbies and the things I like to do at home and in the community
Dated:

Name:

Date of Meeting:

My Wellness
What is important to me and what I would like people to know about my health:

What is important for me and what others should know about my health:

Am I able to take my own medications with or without assistance and what others need to know to support me:

What I need assistance with, if any:

Service Type:

Frequency/Duration:

Who Will Help/Support Me:

Name:

Date of Meeting:

I May Be At Risk of: (Safety, Behavioral and Restrictive Measures)

What people need to know about me is that when I exhibit (explaining the behavior, if any)

What is important for people to know when I act I this way:

How they can support me:

Name:

Date of Meeting:

Housing
What is important for someone to know when coming into my home:

Name:

Date of Meeting:

Employment/Volunteerism/Education
How to be successful in the Four Paths to Employment:

Where do I want to work?

What do I like to do?

What Im good at?

What are my goals?

Do I have Volunteer Opportunities and would I like them?

Educational Needs, if any:

What I need assistance with, if any:

Service Type:

Frequency/Duration:

Who Will Help/ Support Me:

Name:

Date of Meeting:

Self-Advocacy
Do you I have people I trust help me make decisions?

What I need assistance with, is any:

Service Type:

Frequency/Duration
:

Who Will Help/ Support Me:

Name:

Date of Meeting:

What I Enjoy Doing:

Activities:

Service Type:

Frequency/Duration:

Who Will Help/Support Me:

Name:

Date of Meeting:

Consents
Questions
How often would you lie to hear from you Services
and Support Administer?
Where would you prefer to meet with your
Services and Support Administer?
Is there anything you want your Services and
Support Administer to know or assistance you
with

Response

I have chosen who is a part of my circle of supports and participates in my meetings. I understand and agree to
my desires outcomes and supports in my Individual Service Plan. I know that I if I want to make changes to
my person centered plan. I can ask my SSA who can help me contact my circle of supports to update my plan.
I have received the FCOP pamphlet (IO and L1 only) presented to me by
my SSA.
I have received a copy of Form 4074 regarding my due process and appeal
rights through ODJFS.
I have been offered a Voter Registration Card and was made aware that
MCBDD can assist in the process.

(Initials)

I have been offered information about Self-Advocacy

(Initials)

Span Start Date:

Person

(Initials)
(Initials)

Agreements to my plan:
Span End Date:
Signature

Date

Email Address

Relationship

Individual
Parent
Guardian
Other
Signature of those who attended
my meeting

Name:

Date of Meeting:

The following is allow to have a copy of my ISP plan and date sent:
Self_____
Parent______
Guardian______
HPC Provider_____
ADS Provider_____
Transportation_______