CONSUMER RECORD—MAJOR GOALS AND INDEPENDENT LIVING PLAN
Consumer Name
|
Date: ___________ Description / Action Plan:
Goal Code: ___________ ______________________________________________ Proposed Service Code: ___________ ______________________________________________ Date Goal Set: ___________ ______________________________________________ Date Goal Omitted: ___________ ______________________________________________ |
|
Date: ___________ Description / Action Plan: Goal Date: ___________ ______________________________________________ Proposed Service Code: ___________ ______________________________________________ Date Goal Set: ___________ ______________________________________________ Date Goal Met: ___________ ______________________________________________ Date Goal Omitted: ___________ ______________________________________________ |
Goals: Funding Codes
A. Housing & Living Arrangements J. Employment 1. GA Grant-Title VII, Part B
B. Income/ Benefits K. Communication 2. Non Available
C. Transportation L. Social, Recreation, & Community 3. Other
D. Self Care M. Advocacy & Legal Rights 4. Fed. Grant, Title 7,Part C (GA/TN
E. Mobility N. Peer Support 5. Advocacy Grant (GA/TN)
F. Attendant O. I L Skills Training 6. TN Rural Outreach-Title 7 Part B
G. Health Care & Nutrition P. Prostheses & Other Appliance
H. Assistive Devices Q. _________________________
Education
Proposed Core Services: Other Proposed Services:
A. Information & Referral E. Attendant N. Communication
B. Advocacy F. Housing O. Legal
C. Independent Living Skills G. Equipment P. Skills Training (Group)
D. Peer Counseling H. Transportation Q. I L Services Coordination
I. Social/Recreation S. I L Plan
L. Vocational T. I L Evaluation
M. Supported Employment V. Administration
I was directly involved in the development of this Independent Living Plan and agree to participate in these services.
_____________________________________________________________________/_____________________________________
Consumer Signature / Witness Date Staff Signature Date