Independent Living Plan

T.A.R.P. Center for Independent Living
Consumer Goals and Independent Living Plan

* Indicates required field

Name *

First

Last

Date Begun *

County of Residence *

Target Date *

COVID Related? *

Yes No

My Goal is: *

This will help me to: *

Steps I will take in order to achieve my goal.

Step 1 *

Step 2 *

Step 3 *

I was directly involved in the development of this Independent Living Plan and agree to
participate in these services. I understand that I am not legally bound as a contract but I
affirm that I am committed to work toward achieving these goals and hope to achieve the
first goal by:

Goal Date *

Approval or Waiver of Independent Living Plan *

I accept the Independent Living Plan outlined above. I will work alone or with my ILS toward my goals. I waive the right to establish an Independent Living Plan. I choose to develop my goals on my own and will seek advocacy when I feel it is needed.

Todays Date *

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

Any request for services or equipment is subject to approval and availability.

Upon approval you will be notified.

ILS Signature *

Date *

Submit

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