ISP Reading Requirement/Training Review Form

Your Name *

First

Last

Date *

Email *

Date staff are

Phone *

Client Name *

First

Last

For Last Name, please only type in First Initial of client's Last Name (ie. Smith = S)

Client Phone *

PA County of Client *

Please select the service(s) you provide. You can select multiple services. *

Please provide the frequency and duration of hours you provide. For example: 5x's a week for 40 hours, Tuesday and Thursday, 8 hours *

Provide Contact Information in the following section:

#1. Describe your client’s living accommodation; lives at home, in a group home, with a respite provider etc. *

Name (Primary Contact) *

First

Last

Phone (Primary Contact) *

Email (Primary Contact) *

If known

#2. Does your client have a Behavior Consultant? *

#3. Are there other staff on this case? If so, please provide their role: *

YES (please describe)
NO

#4. Is there a Nurse assigned to this case? *

YES (If so, what medical condition requires nursing care?)
NO

ISP GOALS AND OUTCOMES

#1. What are the individual's likes and dislikes? What are the individual's preferred activities? *

#2. What medical and dietary needs are noted in the ISP? How will you assist with those needs? *

#3. Name any issue that may prevent the individual from accessing the community; this may include but is not limited to a specific need such as: the use of a wheelchair, any transportation requirements, concerns with the ability to self-navigate or an unsteady gait. With these issues in mind, what strategies should you use to help the individual access the community? *

#4. What are the individuals' preferred modes of communication? If an assistive device is used, how must you assist the individual communicating? *

#5. Does the individual use any adaptive equipment? This may include but is not limited to glasses, hearing aids, CPAP etc. If so, how will you assist with those needs? *

#6. What are the individuals' supervision care needs as noted in the ISP? *

#7. Does the individual have alone time in the community? If so, how much and at what level? For example, are you required to be side by side, within arm's reach, or does the ISP allow you to be separated? (If you can separate, for what period of time?) Please explain. *

#8. Given the individual’s ISP, please write a short billing note. This should include ideas captured from the answers you have provided above as well as your plan to keep them safe. The notes guide will be included with this document. *

#9. Do you require additional training? *

#10. Please provide any additional comments *

Signature of Authorization *

Clear Signature