Individual Human and Home and Community Based Services (HCBS) Rights Acknowledgement Form

I   acknowledge and confirm that I have been informed of and provided a copy of my Human and HCBS rights as listed below:

• To be treated with dignity and respect
• To be told about your treatment
• To have a say in your treatment
• To speak to others in private
• To have your complaints resolved
• To say what you prefer
• To get help with your rights
• To confidentiality
• To the least restrictive setting

If you have questions or need help, see Dr. Alexander C. Moore, CEO (757) 337-3968 or contact:

Regional Advocate: Reginald T. Daye
     Regional Advocate, Region V
     Eastern State Hospital
     4601 Ironbound Road
     Williamsburg, Virginia 23188
     (757) 253-7061

The setting services are provided in shall:

• Facilitate individual choice regarding services and supports as well as who provides the service and support.
• Ensure the individual’s right to privacy, dignity, respect and freedom from coercion and restraint.
• Support full access to the greater community in an integrated fashion. This includes opportunities to engage in community life, control personal resources, receive services in the community with the same level of access as individuals not receiving Medicaid HCBS.
• Optimize but does not regiment individual initiative, autonomy and independence in making life choices. This includes but is not limited to daily activities, physical environment and with whom to interact.

1. Be physically accessible to the individuals
2. Support the individual’s freedom to control their own schedules and activities as well as have access to food at anytime.
3. Have units that are rented or occupied under a legally enforceable agreement by the individual who has at a minimum the same responsibilities and protections from eviction that tenants have under the landlord/tenant law,55.248.2 of the code of Virginia.
4. Support individuals to have visitors of their choosing at any time.
5. Support the individual’s privacy while they are sleeping or living in the unit by:
   1. Units have entrance doors lockable by the individual with only appropriate staff having keys to doors.
   2. Individuals sharing units have a choice of roommates.
   3. Individuals have the freedom to furnish and decorate their sleeping or living units within the terms of their lease.

Any modification of these requirements specified in items 2-5 above must be supported by a specific assessed need and justified by documentation in the person-centered service plan as follows:

• Identify a specific and individualized assessed need.
• Document less intrusive methods of meeting the need that has been attempted but failed to work.
• Document the positive interventions and supports used prior to any modifications to the person-centered service plan.
• Regular collection and review of data to measure the ongoing effectiveness of the modification.
• Informed consent of the individual
• Established time limits for periodic reviews to determine if the modification is still necessary or can be stopped.
• Include an assurance that interventions and supports will cause no harm to the individual.

• All Kemetic Services staff will be trained on the HCBS rights in conjunction with the mandated training required by 12VAC35-115; questions regarding these rights will be included in the objective written test administered during the initial staff in-services and annually.
• Elements of the listed rights and practices for implementation are included as appropriate in both the position descriptions and the performance evaluations to emphasize the importance of the HCBS rights.

Signature of Legally Authorized Representative – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Accident / Illness Treatment Authorization

In the event of an accident or illness requiring     to receive emergency medical treatment, I authorize Kemetic Services to obtain such care from his/her personal physician, or any-qualified physician available at the scene. In the event of a medical emergency, I authorize a qualified physician to performany life-saving procedures in the best interest of my health, safety, and welfare.

Signature of Individual, Legal Guardian, Authorized Representative and/or Power of Attorney – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Personal Physician  

Phone  

Address  

City  

State  

Zip  

I authorize Kemetic Services to provide or obtain emergency medical treatment as deemed necessary. I relieve Kemetic Services of any liability for the cost of medical care in the event of illness or accident, while I am in the care of the Kemetic Services program. The individual / receiving services and / or their Authorized Representative are responsible for any charges for services stated above. Kemetic Services will not be responsible for charges for emergency services.

Signature of Individual – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Signature of Legal Guardian / Authorized Representative / Power of Attorney – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Face Sheet

Individual’s Full Name - Last  

First  

Middle  

Date  

Social Security No.  

Date of Birth  

Place of Birth  

Marital Status  
Single     Married     Separated     Divorced     Widowed     

Gender  

Religious Preference  

Phone No.  

Home Address  

City  

State  

Zip  

Medicaid ID No.  

Medicare ID No.  

Other Health Insurance Co.  

Policy No.  

Competent     Incompetent    

Adjuticated Incompetent?   Yes     No

Individual has a Authorized Representative (AR)     

Guardian Name  

Phone  

Address  

City  

State  

Zip  

Authorized Representative Name  

Phone  

Address  

City  

State  

Zip  

Next of Kin Name  

Phone  

Work Phone  

Address  

City  

State  

Zip  

Emergency Medical Information

Whom to Contact in an Emergency

Name  

Relationship  

Phone  

Work Phone  

Address  

City  

State  

Zip  

Name  

Relationship  

Phone  

Work Phone  

Address  

City  

State  

Zip  

Advance Directive?  
Yes - If yes, please provide staff a copy
No

Able to communicate verbally in an emergency?  
Yes    
No

Any History of Substance Abuse?  
Yes    
No

Current significant medical problems (including asthma, cancer history, cardiac history, hypertension, stroke, seizure, diabetes, sexually transmitted diseases, TB, HIV, hepatitis, other communicable diseases):  

Other information (e.g., Sensory and ambulatory problems, walks with a cane, uses wheelchair, other medical needs, conditions affecting transportation services, etc.)  

Food  
     

Drugs  

Stings / Bites  
     

Dietary Restrictions  

Please list both prescription and over-the-counter medications

Medication  

Dosage  

Times  

Purpose  

Add another med?

Dentist Name  

Phone  

Address  

City  

State  

Zip  

Pharmacy Name  

Phone  

Address  

City  

State  

Zip  

Health Insurance Co.  

Policy No.  

Group No.  

Signature of Person Providing the Above Information – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Relationship  

Fall Risk Assessment

This form is used to assess the potential fall risk of an individual being served

Please score each line using the scale below:
4 = High Risk - individual requires close monitoring, supervision and mobility assistance due to a history of falling
3 = Moderate Risk - individual requires close monitoring, supervision and some mobility assistance due to the potential of frequent falls)
2 = Minimal Risk - individual requires occasional monitoring due to an occasional fall
1 = Low Risk - individual rarely falls and usually requires no assistance with mobility
0 = No Risk or history of falling

Points      Individual has a history of recent falls

Points      Individual experiences fatigue / weakness

Points      Individual is experiencing agitation or delirium

Points      Individual is on medications which may cause drowsiness

Points      Individual has a history of hypotension

Points      Individual has impaired mobility

Points      Individual has a history of low or unstable blood sugar

Points      Individual needs frequent toileting

Points      Individual is intoxicated from alcohol or other drugs

Points      Individual has an impaired mental status

Total Points     

Kemetic Services employees will report all falls to the CEO / Program Director and complete an incident report when falls occur. A total score of 10 or more requires that this area be addressed as a health and safety issue.

Person Completing Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Audio/Visual and Video Surveillance Policy

Complete the area for the appropriate program being admitted to.

I give my permission to Kemetic Services to photograph, film, and/or tape record me, with knowledge, in regards to my services received through KEMETIC SERVICES. I also give my permission for this information and material, as well as identifying information (i.e. name, age, disability, work/training background, job task) to be used for professional training, publication in the KEMETIC SERVICES newsletter and community awareness of the KEMETIC SERVICES program.

My signature below indicates that I give my permission to Kemetic Services LLC to photograph film and/or tape record me and/or to be monitored by random or fixed video surveillance equipment while participating in KEMETIC SERVICES programs.

Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date
      - OR -

I give my permission to Kemetic Services LLC to photograph, film, and/or tape record me, with knowledge, in regards to my services received through Kemetic Services. I also give my permission for this information and material, as well as identifying information (i.e. name, age, disability, work/training background, job task) to be used for professional training, publication in the Kemetic Services newsletter and community awareness of the Kemetic Services program.

In order to help insure the safety of individuals served, employees and Kemetic Services property, in Group Home settings only, Kemetic Services reserves the right to monitor its facilities in the common living areas such (as living room, hallways, dining room, laundry room, yards, front and back door) and/or vehicles via video cameras. Bedrooms and bathrooms will never be videotaped.

My signature below indicates that I give my permission to Kemetic Services LLC to photograph film and/or tape record me and/or to be monitored by random or fixed video surveillance equipment while in the common living areas of the group home and/or vehicles during the time I reside at the group home located at 2136 Jeffrey Drive, Norfolk, VA 23518.

Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date
     

Consent to Exchange Information
REACH

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

I   (full name of consenting person or persons) am signing this form for

Individual Name  

Phone  

Birthdate  

SSN  

Address  

City  

State  

Zip  

My relationship to the individual is  
Self
Guardian
Authorized Representative
Parent
Power of Attorney
Other

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment     
Information  
Yes    
No

Financial
Information     
Yes    
No

Benefits - Services Needed,
Planned, and/or Received  
Yes    
No

Medical
Diagnosis     
Yes    
No

Mental Health     
Diagnosis  
Yes    
No

Medical
Records     
Yes    
No

Psychological
Records  
Yes    
No

Educational     
Records  
Yes    
No

Psychiatric     
Records  
Yes    
No

Criminal Justice     
Records  
Yes    
No

Employment
Records  
Yes    
No

Other Information You Want  

Name of Agency
     REACH - Regional, Education, Assessment, Crisis Services, Habilitation

Agency Address
     7025 Harbour View Blvd., Suite 119
     Suffolk, Virginia 23435

Phone
     1-888-255-2989

I want this information to be exchanged ONLY for the following purpose(s):  
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)  
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed  
Yes    
No

This consent is good until (one year) from date of signature

• I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
• I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
• If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Witness - if required  

Consent to Exchange Information
Kemetic Services, LLC

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

I   (full name of consenting person or persons) am signing this form for

Individual Name  

Phone  

Birthdate  

SSN  

Address  

City  

State  

Zip  

My relationship to the individual is  
Self
Guardian
Authorized Representative
Parent
Power of Attorney
Other

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment     
Information  
Yes    
No

Financial
Information     
Yes    
No

Benefits - Services Needed,
Planned, and/or Received  
Yes    
No

Medical
Diagnosis     
Yes    
No

Mental Health     
Diagnosis  
Yes    
No

Medical
Records     
Yes    
No

Psychological
Records  
Yes    
No

Educational     
Records  
Yes    
No

Psychiatric     
Records  
Yes    
No

Criminal Justice     
Records  
Yes    
No

Employment
Records  
Yes    
No

Other Information You Want  

Name of Agency
     Kemetic Services, LLC

Agency Address
     2428 Almeda Ave., Suite 170
     Norfolk, Virginia 23513

Phone
     757-337-3968

I want this information to be exchanged ONLY for the following purpose(s):  
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)  
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed  
Yes    
No

This consent is good until (one year) from date of signature

• I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
• I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
• If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Witness - if required  

Consent to Exchange Information
Community Services Board

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

I   (full name of consenting person or persons) am signing this form for

Individual Name  

Phone  

Birthdate  

SSN  

Address  

City  

State  

Zip  

My relationship to the individual is  
Self
Guardian
Authorized Representative
Parent
Power of Attorney
Other

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment     
Information  
Yes    
No

Financial
Information     
Yes    
No

Benefits - Services Needed,
Planned, and/or Received  
Yes    
No

Medical
Diagnosis     
Yes    
No

Mental Health     
Diagnosis  
Yes    
No

Medical
Records     
Yes    
No

Psychological
Records  
Yes    
No

Educational     
Records  
Yes    
No

Psychiatric     
Records  
Yes    
No

Criminal Justice     
Records  
Yes    
No

Employment
Records  
Yes    
No

Other Information You Want  

Name of Agency
     Community Services Board  

Agency Address  

City  

State  

Zip  

Phone  

I want this information to be exchanged ONLY for the following purpose(s):  
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)  
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed  
Yes    
No

This consent is good until (one year) from date of signature

• I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
• I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
• If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Witness - if required  

Consent to Exchange Information
Primary Care Physician

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

I   (full name of consenting person or persons) am signing this form for

Individual Name  

Phone  

Birthdate  

SSN  

Address  

City  

State  

Zip  

My relationship to the individual is  
Self
Guardian
Authorized Representative
Parent
Power of Attorney
Other

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment     
Information  
Yes    
No

Financial
Information     
Yes    
No

Benefits - Services Needed,
Planned, and/or Received  
Yes    
No

Medical
Diagnosis     
Yes    
No

Mental Health     
Diagnosis  
Yes    
No

Medical
Records     
Yes    
No

Psychological
Records  
Yes    
No

Educational     
Records  
Yes    
No

Psychiatric     
Records  
Yes    
No

Criminal Justice     
Records  
Yes    
No

Employment
Records  
Yes    
No

Other Information You Want  

Name of Physician  

Phone  

Physician Address  

City  

State  

Zip  

I want this information to be exchanged ONLY for the following purpose(s):  
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)  
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed  
Yes    
No

This consent is good until (one year) from date of signature

• I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
• I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
• If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Witness - if required  

Consent to Exchange Information
Department of Behavioral Health and Developmental Services (DBHDS)

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

I   (full name of consenting person or persons) am signing this form for

Individual Name  

Phone  

Birthdate  

SSN  

Address  

City  

State  

Zip  

My relationship to the individual is  
Self
Guardian
Authorized Representative
Parent
Power of Attorney
Other

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment     
Information  
Yes    
No

Financial
Information     
Yes    
No

Benefits - Services Needed,
Planned, and/or Received  
Yes    
No

Medical
Diagnosis     
Yes    
No

Mental Health     
Diagnosis  
Yes    
No

Medical
Records     
Yes    
No

Psychological
Records  
Yes    
No

Educational     
Records  
Yes    
No

Psychiatric     
Records  
Yes    
No

Criminal Justice     
Records  
Yes    
No

Employment
Records  
Yes    
No

Other Information You Want  

Name of Agency
     Department of Behavioral Health and Developmental Services (DBHDS)

Agency Address
     1220 Bank St.
     Richmond, Virginia 23219

Phone
     804-786-3921

I want this information to be exchanged ONLY for the following purpose(s):  
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)  
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed  
Yes    
No

This consent is good until (one year) from date of signature

• I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
• I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
• If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Witness - if required  

Consent to Exchange Information
Virginia Department of Medical Assistant Services (DMAS)

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

I   (full name of consenting person or persons) am signing this form for

Individual Name  

Phone  

Birthdate  

SSN  

Address  

City  

State  

Zip  

My relationship to the individual is  
Self
Guardian
Authorized Representative
Parent
Power of Attorney
Other

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment     
Information  
Yes    
No

Financial
Information     
Yes    
No

Benefits - Services Needed,
Planned, and/or Received  
Yes    
No

Medical
Diagnosis     
Yes    
No

Mental Health     
Diagnosis  
Yes    
No

Medical
Records     
Yes    
No

Psychological
Records  
Yes    
No

Educational     
Records  
Yes    
No

Psychiatric     
Records  
Yes    
No

Criminal Justice     
Records  
Yes    
No

Employment
Records  
Yes    
No

Other Information You Want  

Name of Agency
     Virginia Department of Medical Assistant Services (DMAS)

Agency Address
     600 E. Broad Street
     Richmond, Virginia 23219

Phone
     804-756-7933

I want this information to be exchanged ONLY for the following purpose(s):  
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)  
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed  
Yes    
No

This consent is good until (one year) from date of signature

• I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
• I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
• If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Witness - if required  

Consent to Exchange Information
Department of Human Services (DHS)

I understand that different agencies provide services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

I   (full name of consenting person or persons) am signing this form for

Individual Name  

Phone  

Birthdate  

SSN  

Address  

City  

State  

Zip  

My relationship to the individual is  
Self
Guardian
Authorized Representative
Parent
Power of Attorney
Other

I want the following confidential information about the individual (except drug or alcohol abuse diagnosis or treatment information to be exchanged):

Assessment     
Information  
Yes    
No

Financial
Information     
Yes    
No

Benefits - Services Needed,
Planned, and/or Received  
Yes    
No

Medical
Diagnosis     
Yes    
No

Mental Health     
Diagnosis  
Yes    
No

Medical
Records     
Yes    
No

Psychological
Records  
Yes    
No

Educational     
Records  
Yes    
No

Psychiatric     
Records  
Yes    
No

Criminal Justice     
Records  
Yes    
No

Employment
Records  
Yes    
No

Other Information You Want  

Name of Agency  

Phone  

Address  

City  

State  

Zip  

I want this information to be exchanged ONLY for the following purpose(s):  
Service Coordination and Treatment Planning
Eligibility / Admission Determination
Other

I want information to be shared: (check all that apply)  
Written Information
In Meetings or By Phone
Computerized Data

I want to share additional information received after this consent is signed  
Yes    
No

This consent is good until (one year) from date of signature

• I can withdraw this consent at any time by telling the referring agency. This will stop the listed agency from sharing information after they know my consent has been withdrawn.
• I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, the agency and / or person receiving confidential documents will show me this information.
• If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they request.

Signature of Individual or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Witness - if required  

Plan for Supports

The state of Virginia requires all ISP's and support instructions to be signed.
A final copy of the plan and support instructions will be sent to you once it has been completed.

Nothing should be completed on this section except your signature and date at the bottom.

Desired Outcome  

Life Area  
Employment
Integrated Community Involvement
Community Living
Safety and Security
Healthy Living
Social and Spirituality
Citizenship and Advocacy

Key steps and services to get there  

Activity Statement  

I no longer want/need supports when  

What to record  

Skill Building    
Yes    
No

If yes, describe specific skill  

How Often  

By When  

Signature below confirms that the types, reasons/purposes, explanation, risk, and benefits regarding alternative services that might be advantageous for the person this ISP has been created for have been reviewed.

Signature of Individual – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date

Signature of Substitute Decision Maker – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

Date