Division of developmental disabilities (ddd) Alternative Living Services Plan




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DIVISION OF DEVELOPMENTAL DISABILITIES (DDD)

Alternative Living Services Plan
and Provider Report

(ISP Addendum)






TODAY’S DATE

     

CLIENT NAME

     

DDD NUMBER

     

PROVIDER NAME

     

CASE RESOURCE MANAGER NAME

     

BEGIN DATE OF PLAN

     

END DATE OF PLAN

     

TASK

HOURS

PER MONTH

MILES

PER MONTH

 Establishing Residence

Goals (CRM to complete):



     

     




Comments / Recommendations (for CRM or Provider):




Progress (provider to complete):




Residential Guidelines: (check one or more)

 Health and Safety  Power and Choice  Status  Integration

 Relationships  Competence




 Home Living (personal hygiene, nutrition, home management, communication)

Goals (CRM to complete):



     

     




Comments / Recommendations (for CRM or Provider):




Progress (provider to complete):




Residential Guidelines: (check one or more)

 Health and Safety  Power and Choice  Status  Integration

 Relationships  Competence




 Community Living (community services, shopping, transportation, leisure activities)

Goals (CRM to complete):



     

     







Comments/Recommendations (for CRM or Provider):




Progress (Provider to complete):




Residential Guidelines: (check one or more)

 Health and Safety  Power and Choice  Status  Integration

 Relationships  Competence




 Health and Safety (personal safety, physical/mental/dental health, emergency response planning)

Goals (CRM to complete):



     

     




Comments / Recommendations (for CRM or Provider):




Progress (provider to complete):




Residential Guidelines: (check one or more)

 Health and Safety  Power and Choice  Status  Integration

 Relationships  Competence




 Social Activities (social skills, community integration, relationships)

Goals (CRM to complete)



     

     




Comments / Recommendations (for CRM or Provider):




Progress (provider to complete):




Residential Guidelines: (check one or more)

 Health and Safety  Power and Choice  Status  Integration

 Relationships  Competence




 Protection and advocacy (money management, making choices, asserting

rights)

Goals (CRM to complete):



     

     




Comments / Recommendations (for CRM or Provider):




Progress (provider to complete):




Residential Guidelines: (check one or more)

 Health and Safety  Power and Choice  Status  Integration

 Relationships  Competence




 Other Training (to assist client to live independently)

Goals (CRM to complete):



     

     




Comments / Recommendations (for CRM or Provider):




Progress (provider to complete):




Residential Guidelines: (check one or more)

 Health and Safety  Power and Choice  Status  Integration

 Relationships  Competence




TOTALS

     

     

PROVIDER SIGNATURE

DATE

     

CASE RESOURCE MANAGER SIGNATURE

DATE

     

CLIENT SIGNATURE

DATE

     

LEGAL REPRESENTATIVE SIGNATURE

DATE

     

NEXT REVIEW DATE

     







DSHS 10-269 (REV. 02/2013)


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