6 Steps to Creating an Individual Service Plan (ISP) Tailored to Your Loved One

Your loved one’s Individual Service Plan is a central part of their support coordination journey. Support coordinators work alongside families to create an ISP that is customized and tailored to your loved one’s specific needs and goals. To ensure your loved one’s ISP helps them achieve success, it’s important to understand what is included within the document and how it works. Here’s what you need to know.

What is an ISP?

An Individualized Service Plan (ISP) is a comprehensive and customized document that coordinates and provides prior authorization for all New Jersey Division of Developmental Disabilities (NJ DDD) services and service providers. This planning document is required by the NJ DDD. Its goal is to ensure your loved one has access to the special support they need in order to remain healthy, safe, and an active member within their community.

What information is included in an ISP?

The ISP identifies your loved one’s most important goals, aspirations, and outlines the appropriate services needed to help them reach their fullest potential. The ISP is a living document, adapting to your loved one’s changing needs or goals over time.

Who creates an ISP?

Support coordination agencies create ISPs for individuals, but families play a crucial role in tailoring and customizing the document. By working with family members, support coordinators can create the most accurate, comprehensive document that accounts for all of the things that make your loved one unique.

In this blog post, we review the six steps to creating an ISP and explain how your family, along with a dedicated support coordinator, can tailor it for your loved one.

6 Steps to Creating an ISP Tailored to Your Loved One

#1 –  Assessment & Evaluation

The first and most crucial step in creating an effective ISP is a caring assessment and evaluation of your loved one’s unique needs and circumstances. A support coordinator works closely with you and your family to gather information regarding:

  • Medical history
  • Personal preferences
  • Communication preferences
  • Dreams and aspirations
  • Existing support networks

This step is about understanding your loved one’s strengths, challenges, and goals to create a plan that truly reflects their individuality.

#2 – Person-Centered Planning

A person-centered approach is at the heart of every successful ISP. This step involves placing your loved one at the center of decision-making, ensuring that their preferences and choices are respected and incorporated into the plan. Your support coordinator will utilize the Person-Centered Planning Tool, (PCPT) another document required by the NJ DDD, to learn about your loved one. This discovery document will help the support coordinator create the ISP.

With the support coordinator’s guidance, you and your family will work together to identify your loved one’s values, interests, and goals, helping them lead a more fulfilling and purpose-driven life. This step includes:

  • Discussing your loved one’s needs
  • Considering what makes your loved one unique – like hobbies, interests, relationships, etc.
  • Ensuring your loved one’s personality, culture and background are reflected in the ISP

#3 – Identifying Goals & Objectives

After identifying your loved one’s goals, the support coordinator will translate them to outcomes within the ISP. The support coordinator will assist you in defining specific objectives that align with your loved one’s aspirations and capabilities.

These goals should be realistic and achievable. They may cover a wide range of areas such as health, education, employment and social activities.

#4 – Creating a Timeline

To ensure that the ISP remains a dynamic and adaptable document, it’s essential to create a timeline to accomplish meaningful and measurable goals. A dedicated support coordinator will help you establish a realistic schedule and adjust it as needed to accommodate changes in your loved one’s life or circumstances.

During this step, a support coordinator will:

  • Allocate resources and supports. The timeline helps in allocating the necessary resources, whether they are financial, human or material. It allows for proper budgeting, scheduling of support services, and the identification of any specialized resources that might be needed to accomplish specific objectives. For instance, if your loved one is pursuing higher education, the timeline can outline key benchmark goals, like when to apply for scholarships, register for courses, and seek academic support.
  • Plan for progress and accountability. A well-structured timeline establishes a clear point of reference for measuring progress. It allows you and the support coordinator to periodically assess whether objectives are being met according to the schedule. Planning this from the beginning will help identify any challenges and ensure that progress is being made.

#5 – Consent & Authorization

Once the ISP is complete, it is crucial to obtain consent and authorization to ensure that services and support are provided. A support coordinator will guide you through the process of obtaining legal consent, ensuring that everyone involved understands and agrees to the plan’s implementation. Some key factors in this step include:

  • Legal compliance. Your support coordinator will ensure that all necessary legal and regulatory requirements are met. This includes adhering to any local, state, or federal laws governing the provision of support services and the handling of personal information.
  • Confidentiality and privacy. Only individuals authorized by your loved one should have access to their personal and sensitive information. Consent and authorization procedures help maintain the confidentiality and privacy of this information.
  • Collaboration with service providers. Many support services and programs require formal consent and authorization before they can be accessed. Your support coordinator will work with your loved one to facilitate the necessary agreements and documentation to ensure they can benefit from these services.

#6 – Continuous Monitoring & Review

An ISP adapts to your loved one’s changing needs and goals.  The role of a dedicated support coordinator doesn’t end with the creation of the ISP. They play a vital part in the ongoing implementation and review process. Regular check-ins and assessments ensure that the plan remains relevant and effective, adapting to any changes or new goals that may emerge as your loved one’s circumstances evolve.


Creating a tailored ISP is a collaborative process that involves a support coordinator, your loved one, and family members. Through the six essential steps outlined in this blog, you can ensure that you, your family, your loved one and their support coordinator craft the best possible ISP for your loved one to promote their independence and well-being. Support coordinators guide you along this journey, making sure your loved one’s unique needs and preferences remain central to their care and support.

Want to work with a trusted support coordination agency to create the best ISP for your loved one? Contact Skylands Family Support today.

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