Outcomes

JCIL Independent Living Plan

* Indicates required field

Name *

First

Last

Phone Number *

Email *

What are your Independent Living Goals? What would you be able to do after the service is complete? Please be very specific *

Consumer is the person responsible for all action steps

Action Step 1 *

Start Date *

Action Step 2 *

Start Date *

Action Step 3 *

Start Date *

Action Step 4 *

Start Date *

Choose One *

I Accept the Independent Living Plan outlined above. I will work independently or with my advocate towards these goals. I Waive the right to establish an Independent living plan. I choose to develop goals on my own and will seek advocacy when I fell it is needed.

Today's Date *

Any request for services or equipment is subject to approval and availability. Upon approval you will be notified.

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this form *

I Accept

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