PERSON-CENTERED PLAN Name * First Name Last Name DOB * MM DD YYYY Medicaid ID * Record # PCP Completed On * MM DD YYYY LIFE DOMAINS ASSESSED DURING DEVELOPMENT OF PERSON-CENTERED PLAN Daily Life and Employment * Community Living * Safety and Security * Healthy Living * Social and Spirituality * Citizenship and Advocacy * What do you want to work on? What would you like to accomplish? * What strengths do you currently have? * What are the obstacles to meeting your goals? * ACTION PLAN The Action Plan section of the PCP includes the individual's long-term, short-term goals, Interventions, and time-frames. Long-Term Goal * SHORT-TERM SMART GOAL #1 Goal * Interventions - Provider(s): * Interventions - Individual and/or Natural Support Actions * SHORT-TERM SMART GOAL #2 Goal Interventions - Provider(s) Interventions - Individual and/or Natural Support Actions SHORT-TERM SMART GOAL #3 Goal Interventions - Provider(s) Interventions - Individual and/or Natural Support Actions Thank you!
