An Individual Service Plan (ISP) Template designed to structure and personalize client care for Medicaid waiver and healthcare agencies. This template includes standard sections and fields that will help capture and document essential details to meet both the client’s needs and regulatory requirements.

Individual Service Plan Template

1. Client Information

• Client Name: ___________________________________________
• Date of Birth: ___________________________________________
• Medicaid ID Number: _____________________________________
• ISP Date: ______________________________________________
• Next Review Date: _______________________________________

2. Contact Information

• Primary Contact Name: ___________________________________
• Relationship to Client: ____________________________________
• Phone Number: _________________________________________
• Email Address: __________________________________________
• Emergency Contact Name: _______________________________
• Emergency Contact Phone: _______________________________

3. Service Coordinator Information

• Coordinator Name: ______________________________________
• Coordinator Phone: ______________________________________
• Coordinator Email: _______________________________________

4. Client Background and Assessment

• Medical Conditions/Diagnosis: _________________________________________________________________

• Physical and Cognitive Abilities: ________________________________________________________________

• Strengths and Abilities: ________________________________________________________________________

• Areas Needing Assistance: _____________________________________________________________________

• Relevant Behavioral Information: ________________________________________________________________

5. Goals and Objectives

• Goal #1:
  • Description of Goal: _____________________________________________________________________
  • Objective(s): ____________________________________________________________________________
  • Target Completion Date: __________________________________________________________________
  • Progress Notes (e.g., Monthly/Quarterly): ____________________________________________________
• Goal #2:
  • Description of Goal: ______________________________________________________________________
  • Objective(s): ____________________________________________________________________________
  • Target Completion Date: __________________________________________________________________
  • Progress Notes (e.g., Monthly/Quarterly): ____________________________________________________

6. Service Needs and Supports

• Type of Service Needed: ____________________________________________________________
• __________________________________________________________________________________
• __________________________________________________________________________________

• Frequency of Service: _______________________________________________________________

• Provider/Agency Assigned: ___________________________________________________________

• Service Description: __________________________________________________________________
• ____________________________________________________________________________________
• ____________________________________________________________________________________

• Staff Responsibilities: _________________________________________________________________
• _____________________________________________________________________________________
• _____________________________________________________________________________________

7. Risk Management and Safety Plan

• Known Risks: __________________________________________________
• Preventative Measures: __________________________________________
• Emergency Plan and Contacts: ___________________________________
• Client’s Safety Preferences: ______________________________________

8. Personal Care and Daily Activities

• Daily Routine Support:  __________________________________________________________
• _________________________________________________________________________________

• Dietary Preferences/Restrictions: __________________________________________________
• __________________________________________________________________________________

• Mobility and Equipment Needs: _____________________________________________________
• ___________________________________________________________________________________

• Assistance with ADLs (Activities of Daily Living): _________________________________________
• ___________________________________________________________________________________

9. Medical and Medication Management

• Primary Physician Contact: ___________________________________________________________

• Specialist Contacts (if any): ___________________________________________________________

• Medication Schedule and Details: ________________________________________________________
• _____________________________________________________________________________________

• Allergies and Alerts: __________________________________________________________________

10. Client Rights and Advocacy

• Informed Consent: Documented and signed consent for treatment and ISP implementation.
• Client Rights: Documented acknowledgement of client rights.
• Advocacy and Support Contacts: List agencies, family members, or advocates involved.

11. Review and Signatures

• Service Coordinator Signature: ____________________________
• Date: __________________________________________________
• Client or Guardian Signature: _____________________________
• Date: __________________________________________________
• Other Relevant Signatures (as needed): _____________________

12. Notes and Additional Information

• Additional Comments: ____________________________________
• Date of Last ISP Review: _________________________________

13. Plan Updates and Revisions

• Date of Update: _________________________________________
• Updated Goals/Objectives: _______________________________
• Changes in Services or Needs: ___________________________

Need Assistance with Your Individual Service Plan?

For help customizing this template to meet your state’s specific Medicaid waiver and regulatory requirements, please reach out to us. Waiver Consulting Group provides tailored support to ensure compliance and optimal care planning for healthcare and Medicaid waiver agencies.

Contact Us:

• Phone: 302.888.9172
• Email: licensing@waivergroup.com