Individual planning policy and procedures: Attachment 2 – Intervention plan form (September 2005)
Intervention Plan Form
Intervention plan ________________________________________________ (Specify plan)
Client name: __________________________________ Address: __________________________________ __________________________________
DCD ID: __________________________________ DOB: ______________ Age: __________________ Contact No: _________________________________
IP endorsement date: ________________
IP review date: ____________________
Key worker (if a client of Accommodation Support Services): __________________________Contact No: _______________________
Client goal: __________________________________________________________________________________________________ Service activity - Eg mobility – seating ____________________________________________________________________________ Intervention Plan developed by: _________________________________ Role: _____________________________________
1
Individual planning policy and procedures: Attachment 2 – Intervention plan form (September 2005)
Service phase
Eg. Assessment, implementation, review
Tasks
Resources reviewed and sources of funds
Person responsible
Role
Start date
Planned completion date
Review schedule
(Additional pages should be added if necessary)
2
Individual planning policy and procedures: Attachment 2 – Intervention plan form (September 2005)
Key environmental barriers and facilitators
Additional comments or special considerations
Agreement: Client: (if able to indicate agreement) _____________________________________ Date: _________________ Date: _________________
Family/ Carer/ Person Responsible/ Guardian: ________________________________ Manager: _______________________________________________
Date: _________________
3