NC Division of Mental Health, Developmental Disabilities,
and Substance Abuse Services
Alliance Behavioral Healthcare
Serving Cumberland, Durham, Johnston and Wake Counties
Developmental Disabilities B-3 and/or IPRS Support Plan
THIS PLAN IS TO BE USED FOR INDIVIDUALS WITH I/DD RECEIVING B-3 MEDICAID AND/OR IPRS FUNDED SERVICES
Name:
DOB:
/ /
Medicaid ID:
County of Residence:
Plan Meeting Date:
/
/
MCO Record #:
Effective Date:
/
/
WHAT PEOPLE LIKE AND ADMIRE ABOUT….
WHAT’S IMPORTANT TO….
HOW BEST TO SUPPORT….
ADD WHAT’S WORKING / WHAT’S NOT WORKING
ABHC_08172012
1
Name:
DOB:
Medicaid ID:
Record #:
ACTION PLAN
The Action Plan should be based on information and recommendations from: the Comprehensive Clinical Assessment (CCA), the
One Page Profile, Characteristics/Observations/Justifications for Goals, and any other supporting documentation.
Long Range Outcome: (Ensure that this is an outcome desired by the individual, and not a goal belonging to others).
Where am I now in the process of achieving this outcome? (Include progress on goals over the past years, as applicable).
CHARACTERISTICS/OBSERVATION/JUSTIFICATION FOR THIS GOAL:
WHAT (Short Range Goal)
WHO IS RESPONSIBLE
SERVICE &
FREQUENCY
HOW (Support/Intervention)
Target Date (Not to
exceed 12 months)
Date Goal was
reviewed
/
/
/
/
/
/
/
/
/
/
/
/
Status Codes:
Status Code
R=Revised
Progress toward goal and justification for continuation
or discontinuation of goal.
O=Ongoing
A=Achieved
D=Discontinued
CHARACTERISTICS/OBSERVATION/JUSTIFICATION FOR THIS GOAL:
WHAT (Short Range Goal)
WHO IS RESPONSIBLE
SERVICE &
FREQUENCY
HOW (Support/Intervention)
Target Date (Not to
exceed 12 months)
Date Goal was
reviewed
/
/
/
/
/
/
/
/
/
/
/
/
Status Codes:
R=Revised
Status
Codes
Progress toward goal and justification for continuation
or discontinuation of goal.
O=Ongoing
A=Achieved
D=Discontinued
** Copy and use as many Action Plan pages as needed.
ABHC_08172012
2
Name:
DOB:
Medicaid ID:
Record #:
CRISIS PREVENTION AND INTERVENTION PLAN
Description of the crisis: What does the crisis look like? This can be behavioral and/or medical in nature. What behaviors and/or
symptoms will the person display? How will someone working/interacting with the person know they are in crisis? Describe how long
the behaviors and/or symptoms may last and any changes in severity.
Crisis Prevention: What environmental and social strategies help provide stability for the person?
Triggers to crisis: (What causes the person to go into crisis?
Examples may include noise, inability to express medical
problems or to get needs met, low/high blood pressure,
constipation.)





Crisis Prevention: List what can be done to help the person avoid
each trigger.





Strategies for crisis response and stabilization. If the crisis cannot be prevented, what are the next steps? Focus first on natural and
community supports. Begin with least restrictive steps. List everything you know that has worked to help this person to become stable.
How do you keep this person and others safe?
Diagnosis (DSM-IV/ICD-9CM)
Medication: Include dosage and
frequency.
ABHC_08172012
Axis I:
Axis II:
Axis III:
Axis IV:
Target symptoms of this medication: Why is the individual being prescribed this
medication?
3
Name:
DOB:
Medicaid ID:
Record #:
Contact Information (Include names, relationship and direct phone numbers or extension.)
Primary Contacts:
First Contact:
Telephone #:
Consent/Release of Information:
Yes
Legally Responsible Person:
Telephone #:
Consent/Release of Information:
Yes
(If applicable)
No
No
Lead Agency Contact:
Name:
Telephone #:
Consent/Release of Information:
Yes
No
Natural/Community Supports:
Name:
Name:
Telephone #:
Telephone #:
Consent/Release of Information:
Consent/Release of Information:
Yes
Yes
No
No
Telephone #:
Telephone #:
Consent/Release of Information:
Consent/Release of Information:
Yes
Yes
No
No
Telephone #:
Consent/Release of Information:
Yes
No
Telephone #:
Telephone #:
Consent/Release of Information:
Consent/Release of Information:
Yes
Yes
No
No
Professional Supports:
Name/Agency:
Primary Care Physician:
Preferred Psychiatric Inpatient
/Respite Provider:
Other Supports:
Name:
Name:
Advanced Directives: (Advance Directives allow you to plan ahead for care in the event that there are times that you are
unable to speak for yourself).
Yes
No I have a Living Will.
Yes
No I would like one.
Yes
No I have a Health Care Power of Attorney.
Yes
No I would like one.
Yes
No I have an Advanced Instruction for Mental Health Treatment.
Yes
No I would like one.
**If you check that you would like any of these Advanced Directives, please refer to the Alliance Behavioral Healthcare website
at www.alliancebhc.org , Consumer resources section. **
ABHC_08172012
4
Name:
DOB:
Medicaid ID:
Record #:
I/DD B-3 MEDICAID AND/OR IPRS FUNDED SERVICES SUPPORT PLAN SIGNATURE PAGE
I.
PERSON RECEIVING SERVICES:
I confirm and agree with my involvement in the development of this Support Plan. My signature means that I agree with the
services/supports to be provided.
I understand that I have the choice of service providers and may change service providers at any time, by contacting the Qualified
Professionals/Agencies involved in the development of this Support Plan or Alliance Behavioral Healthcare Access and Information line at
(800) 510-9132 or (919) 651-8400.
Legally Responsible Person: Self: Yes
No
Person Receiving Services: (Required when person is his/her own legally responsible person)
Signature: _____
_____
Date: _________
(Print Name)
Legally Responsible Person (Required if other than person receiving Services)
Signature: _____
_____
Date: _________
(Print Name)
Relationship to the Individual: _________________________________
II.
LEAD AGENCYSIGNATURE: The following signature confirms the involvement of the QP at the lead agency. The signature
indicates agreement with the services/supports to be provided.
Signature: _____
(Lead Agency Qualified Professional)
III.
Date: _________
(Name of Lead Agency Provider)
OTHER PROVIDER SIGNATURE(S): The signature indicates agreement with the services/supports to be provided.
Signature: _____
(Qualified Professional)
Signature: _____
(Qualified Professional)
IV.
_____
_____
Date: _________
(Name of Agency Provider)
_____
Date: _________
(Name of Agency Provider)
SIGNATURES OF OTHER TEAM MEMBERS PARTICIPATING IN DEVELOPMENT OF THE PLAN:
Other Team Member (Name/Relationship): _____
Other Team Member (Name/Relationship): ______
ABHC_08172012
_____
_____
Date: _________
Date: _________
5