Question	Answer
Form Name	Individualized Service Plan Form
Form Length	5 pages
Fillable?	Yes
Fillable fields	372
Avg. time to fill out	37 min 49 sec
Other names	assisted living service form, service plan forms for assisted living, assisted living service plan samples, assisted living plan

	Assisted Living Individualized Service Plan (ISP)
Resident Name:			Female Male
Date:		For: Initial Six months Other ___________

Activity – Check all		Services to be provided:		Frequency	By	Changes/Comments
applicable					Whom

Medical - Nursing

Lab Test

Pacemaker

Dialysis

Skilled Nursing,		Injection Insulin
Treatments &/or		Injection Insulin
Education		Other – Type __________________
		Dressing
		Other ________________________

Specialists (eg		Specify________________________________
podiatrist,		Specify________________________________
chiropractor)	________________________________________
	________________________________________

Medical Equipment		Independent
		Type _______________
		1+ Assist (requires more than	–
		intermittent assistance with equipment	–
		EALR required)

Pain Management

Other		health prevention
		aide-level health related activities
		other – specify____________________
	__________________________________

Resident Name: ________________________________________ Date: ____________							ISP Page 2 of 5

Activity – Check all	Services to be provided:				Frequency	By	Changes/Comments
applicable						Whom
Fluid Restrictions/	None
Encouragement	Dietary Supplements _______________
	Other Specify: __________________


Functional
Personal Hygiene	Independent
	Shower	Bath		Equipment
	Hearing Aide:		R	L
	Eyeglasses Reading Always
	Hair: Shampoo Grooming Shave
	Teeth Care Denture Care
	Nail Care	Foot Care
Continence	Independent
	Assist with bathroom
	Assist with protective garment change
	Ostomy Care
	Chronic unmanaged incontinence
	(chronically unwilling or unable to
	participate, with help from staff, so that
	cleanliness and sanitation can be
	maintained - EALR required)

Skin Care	None
	Location & Type: _________________

Dressing	Independent
	Coordinate Upper Lower
	Other _________________________

Medications	Self Assist

Transfer	Independent
	1+ Assist (chronically chairfast and/or
	chronically needs one person assist to
	transfer – EALR required)

Mobility	Independent		Walker Cane
	Wheelchair	Crutches
	Escort: _______________________
	1+ Assist (chronically needs one person
	to assist to walk or to climb/descend stairs-
	EALR required)
Falls Risk Reduction	No Known History
	Other: __________________________

Respiratory Therapy	None Self-managed
& Oxygen	Type: _________________________

Equipment	None Self-managed
	Prosthesis	Braces
	Other __________________________

Resident Name: ________________________________________		Date: ____________		ISP Page 3 of 5

Activity – Check all	Services to be provided:	Frequency	By	Changes/Comments
applicable			Whom
Cognitive
Orientation	N/A Remind Cue Supervise
	Accompany
Specialized Services	N/A
	Dementia Care, Secured Unit (requires
	SNALR)
	Environmental modifications
	Supervision/Monitoring

Sensory	None
	Hearing Vision Speech
	Other: ________________________

Mental Health	Diagnosis: _____________________
	Treatment Required ___Yes ___No
	Substance Abuse
	Coordination with SA
	provider__________________________

Social
Education &	Desire for continued or future education:
Employment	Yes No
	If yes, specify: ___________________
	Desire to work or volunteer
	Yes No
	If yes, specify: __________________

Intellectual	Desire for new or continued intellectual
	activity
	Yes No
	If yes, specify: ___________________

Recreational	Desire for new or continued recreational
	activity
	No Yes, Specify: _______________
	Need assistance of ALR staff
	Specify: ______________________

Spiritual	Desire for new or continued spiritual activity
	No Yes, Specify: ________________
	Need assistance of ALR staff
	Specify: _________________________

Cultural	Desire for new or continued cultural activity
	No Yes, Specify: ________________
	Need assistance of ALR staff
	Specify: _________________________

Financial	Assistance with access to financial benfits
	(i.e. Medicare, Medicaid, Social Security,
	Veteran’s Admin., Pensions, etc.)
	Managed Independently
	Assistance of family, resident rep. or
	legal rep. Specify: __________________
	Need assistance of ALR staff
	Specify: _________________________

Was the Resident’s Primary Physician Consulted?
Yes	Indicate physician’s name and date:	______________________________	_________________
No
__________________________________________		________________________________________		__________________
Home Care Services Agency Rep. Signature		ALR Provider’s Representative Signature		Date

_______________________________	______________________	____________	______________________
Name	Title	Date	Signature

Instrumental
Activities of Daily
Living
Transportation	independent, drives own car or accesses
	transportation on own & chooses to do so
	wants or needs someone to drive them,
	but does not require an escort
	must be accompanied by an escort
	requires special transportation
	specify ___________________

Laundry	is able & chooses to do own laundry
	is able & chooses to do light laundry, but
	wants/needs assistance with heavy laundry
	needs or chooses ALR to do all laundry

Housekeeping	is able & chooses to do all housekeeping
	tasks in room/apartment
	is able & chooses to do light
	housekeeping, but wants/needs assistance
	with heavier cleaning tasks
	Specify _________________________
	needs or chooses ALR to do all
	housekeeping
Shopping	is able & chooses to shop on their own &
	carry or transport packages on their own
	is able & chooses to do light shopping on
	their own, but wants/needs assistance with
	major shopping
	Specify _________________________
	needs or chooses ALR staff or other
	person (i.e. family member) to do all of their
	shopping
Ability to use	Independent-has phone & dials numbers
telephone	and answers calls without assistance
	has specially adapted phone and dials
	numbers and answers calls without
	assistance
	chooses or needs ALR staff to help them
	make calls or make the calls on their behalf

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