IMPLEMENTATION PLAN	IP Date
Individual
Social Security #	Medicaid #	Medicare #
Complete one Signature page with all required information. The Signature page will be the cover sheet for the Implementation Plan for all services. For each goal, complete one IP-Goal Action Plan. When the IP is completed, submit to the office for review. When the IP is approved, obtain signatures and submit a copy to the client, the guardian, the office, and to the WSC.
Client Address

Phone #
Cell Phone #
Date Services Began
SP Meeting Date
SP Effective Date
Date SP Received	Stamped Support Plan Received
IP Effective Date
Date IP Written
SPA Form Received
SUPPORTS
Support	Name	Phone #
Emergency Contact/Relationship
Guardian/Family
Friend(s)
Support Coordinator/Agency
Program Administrator	Amy Martinez	727-841-7161
Staff
SIGNATURES
Individual	Signature	Receipt Method (fax, by hand, meeting etc)	Date
Client
Guardian
Staff
WSC
EVALUATION: The instrument used for evaluation of the individual's goal progress is the service logs.
STAFF ACCESS: The method for accessing a supported living staff person 24/7 is through staff pagers/cell phones.
DATA COLLECTION: The system used to assess client progress: service log, monthly summary, and quarterly summary. Satisfaction of service will be noted in service log, quarterly status report, and annual satisfaction survey. Projected outcomes will be monitored quarterly to assess progress and the need for changes to IP.
STAFF AND NATURAL SUPPORTS: Describe the supports that are available to assist the individual with his goals.

HEALTH AND MEDICAL ISSUES: Describe health and medical issues that may impact the client's work on his goals.

HOME & COMMUNITY SAFETY NEEDS & SUPPORTS: Describe the client's needs and the supports required to address safety.

OTHER SUPPORTS/SERVICES NEEDED: State any supports and services not related to the goals needed to ensure the health, safety, and well-being of the client that are not on the SP. Areas include health, safety, household tasks, meal preparation, community inclusion, self care, personal growth, financial, leisure time, shopping, etc.