Easter Seals Iowa
Individual Program Plan (IPP)
Name:
Program:
Date started:
Where services take place:
My goal/outcome:
My obstacle to achieving my goal:
What I am going to do to reach my goal:
When I expect
to reach my
goal.
Day I reach my
Goal
1.
2.
3.
4.
5.
Methods (How I am going to track my progress):
Person(s) Responsible:
I understand my goals and what I am responsible for.________________________
Participant Signature
______________________________Legal Guardian
__________________________________________________________________
Implementer
Date applicable
__________________________________________________________________
Implementer
Date applicable
Revisions to individual program plan: _____________________________________
______________________________________________________________________
ESC – 1165, 10/97, 3/99 Revised 4/01
Date: ______________
Program Participant: _____________________________
Legal Guardian: _____________________
Implementer: _________________
Participant input at halfway point (vocational and SCL): _____________________
______________________________________________________________________
This plan helped me to reach the outcome I expected:
YES
NO
_______________________________________________
Participant Signature
Facilitator’s Notes
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Anyone entering an Easter Seal program must have goals written within their first 30
days in the program.
IPPs should actively involved the person served, should be realistic, and contain
attainable goals.
IPPs should be specific, and be taken from the intake recommendations when
applicable.
“What you are doing to reach your goal,” must relate directly to the goal.
“Obstacles” are things that prevent the participant from reaching their goals.
Each IPP can have one revision and then must be rewritten. It will not be considered
a revision, if the implementor changes.
Progress notes should be made at least monthly; they need to include a summary of
the participant’s progress or lack of progress, and relate to the goal.
At the half way point of the IPP, the participant will be asked whether or not the plan
is helping meet his or her goals. If it is not, a new goals needs to be written. This
will be documented on the back of the IPP sheet. This will be in addition to the
monthly progress notes.(vocational and scl only)
Any time an IPP is closed out, the participant should circle whether or not the plan
helped them reach their goal, and sign.
It will be considered a revision, if goals are extended. It must clearly state this in the
revision section on the back. On the front of the IPP, put one line through the old
date and write new date above it and initial. Do not write anything else on the front.
If client is receiving Adult Rehab Option Services, the goals have to be rehabilitative
in nature. Goals should be reflective of CCSP goals.
Goals should support the Essential Lifestyle Plan when appropriate.
ESC – 1165, 10/97, 3/99 Revised 4/01
Travel Time: __________
On-Site Time: __________
Iowa Rural Solutions
INITIAL ASSESSMENT/INTERVIEW
The initial assessment/interview needs be typed within three weeks of the date the
assessment was performed. The hand written copy should initially be kept in the file
until the typed version can replace the hand-written version.
DATE:
CONSUMER’S NAME:
CONSUMER’S ADDRESS:
TELEPHONE:
DIRECTIONS:
SPOUSE’S NAME:
DISABILITY:
DATE OF DISABILITY:
DATE OF BIRTH:
MEDICAL:
 Doctor’s name, PT’s name, Homehealth Aid name (list the name of any medical
professional working with the consumer)
 The stage the consumer is in with the rehabilitation process
 The consumer’s prognosis
 Cause of disability
 Physical limitations
 Physical abilities
 Current contact with medical professionals
 Do they have and if so what kind of insurance do they have
 List any durable medical equipment they are currently using
 List any durable medical equipment they are in need of or are in the process of
obtaining
ACTIVITIES OF DAILY LIVING:
 All areas of the Independent Living Assessment
 ADL needs/goals
 Current ADL modifications utilizing
 What is the layout of their house, is it accessible?
 If needed, who assists with ADL’s?
ESC – 1165, 10/97, 3/99 Revised 4/01
SOCIAL AND PSYCHOLOGICAL
 Did they agree to be matched with a peer support person?
 Did they freely talk about the adjustment process to a disability?
 Do they belong to a support group?
 Do they belong to a church or a civic organization?
 What is the familial arrangement?
 What other organizations is the consumer working with?
 What type of support system do they have?
EDUCATIONAL/VOCATIONAL
 Are they currently employed, if so in what area (off-farm and on-farm
employment)?
 What is their past work history?
 What vocational interests do they have?
 Are they planning to change careers?
 If they have been unable to work, do they plan to return to the same job?
 What, if any job tasks would they have difficulties performing?
 Are they receiving SSDI, SSI, Worker’s Comp, or have they applied?
SUMMARY CONCLUSIONS
A paragraph or two summarizing the information above.
GOALS
Goal #1 (time frame expected to accomplish goal)
Objective(s) needed to reach Goal #1
Goal #2 (time frame expected to accomplish goal)
Objective(s) needed to reach Goal #2
STAFF PERSON
Staff person’s name should be typed and signed by staff.
(All Initial Assessment/Interviews needs to be signed-off by the Program Director.)
ESC – 1165, 10/97, 3/99 Revised 4/01
Easter Seals FaRM Program
Referral Form
Client status:
 New

On-going

Re-opened case
Date of Referral: _______ Referral Form Completed By: __________________
Staff Person Assigned to New Referral:_______________Staff Code: ________
Client’s Name: ______________Client ID #_____ Social Security # __________
Address: ______________________City_________ Zip _____ County _______
Telephone: ____________(h) _____________ (w) E-mail Address ___________
Gender: M  F  Date of Birth: _____ Age: ___ Spouse/Parent’sName:
____________________
Directions to Home: ________________________________________________
______________________________________________________________________
__________________________________________________________
Spouse/Parent’s Address (if different from above)
Address: ______________________City_________ Zip _____County _______
Telephone:____________ (h) _____________ (w) E-mail Address ___________
Referral Source’s Name:_______________Telephone Number: ___________
Organization: ______________________________ E-mail Address __________
Address: ______________________City_________ State _____ Zip ________
How did Client or Contact hear about AgrAbility? (Check ALL that apply)
 Former/current AgrAbility
 Ag professional
Media:
Client
 Health prof.
 TV
 Non Profit AgrAbility staff
 VR professional
 Radio
 Extension staff (AgrAbility)
 General public
 Newspaper
 Extension staff (non AgrAbility)  Other ______
 Magazine
 Family member
 Other ______
 Other individual w/disability
Total number of people in household: __________
ESC – 1165, 10/97, 3/99 Revised 4/01
Who are the stakeholders involved in this situation? (Check ALL that apply)
 Spouse/partner
 Parents
 Other relatives
 Neighbors
 Children
 Other
 Business partners/shareholders
 Siblings
__________
Type of Agricultural Operation: (check those that apply) Number of Years in Operation: ____________
 Agri Business
 Aquaculture
 Cotton
 Dairy
 Field/Grain Crops  Forestry
 Fruit/fruit nut  Orchard crops
 Livestock
 Poultry
 Nursery
 Vegetable
 Hay
 Other animal  Specialized crops (e.g. mushrooms, flowers)
Other ___________________________________________________________
Who is the client? (Check ONE)
 Owner/Operator
 Spouse/partner
 Dependent adult
 Child (< 18 years)
Work status at time of referral.
 None
 Full time
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No longer actively farming/ranching
Employee
Migrant
Seasonal worker
Current work role on farm (Check ONE)
 Part time (regular basis)
 Occasional (irregular basis, several
times a
year)
Origin and Date of Disability:
Agriculture-related
Non Agriculture Related
 Auto/truck accident
Date ________ Auto accident
Date _________
 Chemicals/pesticides
Date ________  Fall(s)
Date _________
 Farm machinery
Date ________  Recreational
Date _________
 Fall(s)
Date ________  Other ______
Date _________
 Livestock/animals
Date ________
 Other
Date ________
ESC – 1165, 10/97, 3/99 Revised 4/01
Type of Disability at time of referral (Check ALL that apply)
Category
Injury/Amputation
Neuromuscular
Diseases
Neurological
Condition/Disorder
Specific Disability Type
Amputation (Upper Extremity)
 Above elbow
 Below elbow
 Hand
 Finger
 Thumb
Amputation (Lower Extremity)
 Leg – Above knee
 Leg – Below knee
 Foot
 Toe
Replant (specify) _________
 Amyotrophic lateral sclerosis
 Friedreich’s ataxia
 Guillain-Barre syndrome
 Huntington’s disease
 Muscular dystrophy
 Myasthenia gravis
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Other Disease
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Sensory
Impairments
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Other
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Back injury
Joint injury (shoulder,
elbow, wrist, hip)
Orthopedic injury (other)
Spinal cord injuryparaplegic
Spinal cord injury quadriplegic
Traumatic brain injury
Other ____________
Parkinson’s disease
Poliomyelitis
Spinal muscular atrophy
Spinocerebellar
degeneration
Other____________
Cerebral vascular accident (stroke)
Cerebral palsy
Epilepsy
Multiple sclerosis
Peripheral neuropathies
Other____________
Blood related disease (hemophilia, sickle cell anemia, leukemia)
Cancer
Cardiovascular disease
Chronic obstructive pulmonary disease (Respiratory impairment)
Chronic fatigue syndrome
Fibromyalgia
Kidney disease
Arthritis /Rheumatic diseases
Other____________
Deafblind
Hearing impairment
Visual impairment
Other____________
Chemical dependency
Chemical sensitivity
Diabetes/metabolic disorder
Mental illness
Mental retardation
Other____________
ESC – 1165, 10/97, 3/99 Revised 4/01