TEAM MEMBER CONTRIBUTION

 

To be completed after an assessment/observation and to be brought to the ISSP Team meeting, or forwarded to the Manager if member is unable to attend. This sheet may be retained by each team member in his/her own file on child/youth.

CHILD/YOUTH______________________________________

 

STRENGTHS NEEDS

 

INDIVIDUAL SUPPORT SERVICES PLAN

TEAM MEMBERSHIP

 

NAME OF CHILD___________________________DATE OF BIRTH_____________________________

ADDRESS____________________________________________________________________________________

COMMUNITY_________________________________REGION________________________________________

SCHOOL____________________________________DISTRICT________________________________________

TEL. NO. ___________________________ISSP MANAGER____________________________________

DATE TEAM ESTABLISHED_____________________________

DATE OF TEAM MEETING_______________________________      _____________________________

                                                  _______________________________      _____________________________

 

NAME PHONE/FAX AGENCY/ADDRESS
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

NOTE NAME OF ISSP MANAGER SHOULD APPEAR IN THE LIST

 

INDIVIDUAL SUPPORT SERVICES PLAN
( Strengths & Needs Agreed by Consensus of Team )

 

CHILD/YOUTH______________________________________

 

STRENGTHS NEEDS

 

INDIVIDUAL SUPPORT SERVICES PLAN
( Goals Agreed by Consensus of Team )

 

CHILD/Youth___________________________________

 

Goals To be implemented by Environment(s) Date of Review

 

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INDIVIDUAL SUPPORT SERVICES PLAN
MANAGER'S RECORD

 

Individual Support Services Managers will contact members on actual review date and make appropriate notations.

 

Goals/Service Area Date

 

INDIVIDUAL SUPPORT SERVICES PLAN
SUMMARY

 

CHILD/YOUTH______________________________________

 

Comments__________________________________________________________________________________________

____________________________________________________________________________________________________

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____________________________________________________________________________________________________

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Signature

________________________________      Parent___________________________________

________________________________      Child____________________________________
                                                                                                   (If Participant)

_______________________________        Position_________________________________

_______________________________        Position_________________________________

_______________________________        Position_________________________________

_______________________________        Position_________________________________

_______________________________        Position_________________________________