Independent Living Plan/Waiver

Name: Consumer Goals

Start Target Actual

Goal Narrative Start
Date Target
Date End
Actual
Date
Goal Narrative Date Date End
Date

Person who is
Objectives Responsible
Person who is
. Objectives Responsible

 I am eligible for PIRS services and I was directly involved in the development of the above
Independent Living Plan (ILP).

 I have been told about an Independent Living Plan (ILP) and its function. I am eligible for
services from PIRS but do not wish to develop an ILP at this time. I am aware that I may
develop an ILP at a later date if I would like to do so.

_____________________________________ ____________________________________
Consumer Signature Date Staff Signature Date

6/11 C-1

Consumer Goals
A) Self-care - Goals to improve/maintain an individual’s autonomy with respect to activities
of daily living such as personal grooming and cleaning, toileting, meal preparation,
shopping, eating, etc.

B) Communication - Goals involving either improvement in the consumer’s ability to

understand and acknowledge communication by others (receptive), or improvement in
one’s ability to produce verbal language, sign language and other communication
(expressive).
C) Mobility - Goals to improve an individual’s access to his or her life space, environment or
community. This increase in access may occur by improving the person’s own ability to
move or transport himself or herself, or by allowing the consumer to be moved to
transported by another person.

D) Residential - Goals that provide for change in living situations with increased autonomy
for the individual with significant disabilities.

E) Education - IL goals of an academic or training nature that are expected to improve the
consumer’s basic knowledge or increase his or her ability to perform certain skills.

F) Vocational - IL goals related to obtaining, maintaining, or advancing in employment.

G) Other - Other IL goals not included in the above categories.

6/11