Individual Service Plan

Individual Service Plan Goodwill Industries of Wayne and Holmes Counties

Consumer *

Date *

Date

Vocational Service

Vocational Goal

Case Manager *

Referring Agency/Counselor

WFT OSP Chosen

(This section is for OOD Work Assessments Only)

Work Site

Total Hours

Work Schedule

Start Date

Date

Job Coach

Objective 1 - Issue to be Evaluated

Objective 1 - How is this Evaluated? (Method Used)

Objective 1 - Measurement (Technique Used)

Objective 1 - Assistive Technology Required

Objective 1 -Who is Involved? (People Responsible)

Objective 1 -Timeframe to Accomplish

Objective 2 - Issue to be Evaluated

Objective 2 - How is this Evaluated? (Method Used)

Objective 2 - Measurement (Technique Used)

Objective 2 - Assistive Technology Required

Objective 2 -Who is Involved? (People Responsible)

Objective 2 -Timeframe to Accomplish

Objective 3 - Issue to be Evaluated

Objective 3 - How is this Evaluated? (Method Used)

Objective 3 - Measurement (Technique Used)

Objective 3 - Assistive Technology Required

Objective 3 -Who is Involved? (People Responsible)

Objective 3 -Timeframe to Accomplish

Objective 4 - Issue to be Evaluated

Objective 4 - How is this Evaluated? (Method Used)

Objective 4 - Measurement (Technique Used)

Objective 4 - Assistive Technology Required

Objective 4 -Who is Involved? (People Responsible)

Objective 4 -Timeframe to Accomplish

Objective 5 - Issue to be Evaluated

Objective 5 - How is this Evaluated? (Method Used)

Objective 5 - Measurement (Technique Used)

Objective 5 - Assistive Technology Required

Objective 5 -Who is Involved? (People Responsible)

Objective 5 -Timeframe to Accomplish

Objective 6 - Issue to be Evaluated

Objective 6 - How is this Evaluated? (Method Used)

Objective 6 - Measurement (Technique Used)

Objective 6 - Assistive Technology Required

Objective 6 -Who is Involved? (People Responsible)

Objective 6 -Timeframe to Accomplish

Objective 7 - Issue to be Evaluated

Objective 7 - How is this Evaluated? (Method Used)

Objective 7 - Measurement (Technique Used)

Objective 7 - Assistive Technology Required

Objective 7 -Who is Involved? (People Responsible)

Objective 7 -Timeframe to Accomplish

I understand the objectives of this plan and the issues to be explored, how these objectives will be accomplished, and have received a copy of this plan.

Consumer Signature

Clear

The person signing this form was

Guardian Name if Applicable

Date

Case Manager Signature

Clear

Date

How was this form completed with the client?

Case Manager Name