Attachment G

Chapter 4, Part 2 – Program Activities

INDIVIDUAL SERVICE STRATEGY (ISS)

BACKGROUND INFORMATION
Participant Name: / Phone Number: / Date of Enrollment:
Address: / City/State/Zip Code: / Birth date:
Case Manager: / Referral Source/Contact Information: (if applicable)
Educational History
Attending School: YES NO / Current Grade Level/#of Credits: / Name of School:
Dropped Out of School:
YES NO / Highest Grade Completed/# of Credits: / Last School Attended:
Competed High School Diploma/GED:
YES NO / Date Completed: / School/Program:
If Dropped Out, Why?
Ever Attended Post Secondary School:
YES NO / School: / Area of Concentration/Study:
List any other Diplomas/Degrees/Licenses/Certifications:
List any additional Educational/Vocational Training Courses taken:
Other Comments on Educational History:
Employment History
Job Title & Duties / Employer / Dates WorkedReason for Leaving
Describe any other work experience and/or skills learned through volunteering, hobbies, etc:
Other Comments on Employment History:
BARRIERS
Education and Training Barriers:
Low Math/Reading Skills
Dropped out of school
Learning Disability
/
Attendance
Grades/Credits
Suspensions/Expulsions
/
English (Speaking/Reading/Writing)
First Generation High School Graduate
Comments:
Employment Barriers:
Work Clothing
Equipment/Tools
Criminal History/Record
/
No Picture ID
Lack of career goals
Lack of vocational skills
/
No work history

Poor work references

Comments:
Life skills Barriers:
Housing
Food
Clothing
Transportation
Pregnant/Parenting
Child Care
Healthcare
Driving License / No social security card
Legal Issues
Budgeting
Financial/Credit History
Gang Affected/Involved
Currently in foster care/ward of court
Formerly in foster care/ward of court
Is/was raised by someone other than biological parents / Family Issues/Instability
Parent/Guardian incarcerated
Substance Abuse
Mental Health/Counseling
Self-Esteem
Depression
Motivation
Anger Management
Comments:
Additional Barriers/Comments:
ASSESSMENT RESULTS SUMMARY
Academic Skill Assessments
Name of Test & Version Used:
Pre-Test ScoreDate Taken: / Post Test Scores & Date Taken: (if applicable)
Math: / Math:
Reading: / Reading:
Writing: / Writing:
Other Academic Assessment Results/Comments:
Academic Needs/Accommodations (please include any Individual Education Plan [IEP] Information [if applicable]):
Other Assessment Results
Interest/Aptitudes: (please list any tools used to assess)
Career/Employment: (please list any tools used to assess)
LifeSkills: (please list any tools used to assess)
Other Assessment Results/Comments:
TRAINING PLAN/GOALS
Goal(s): / Steps to Accomplish Goal:
(list type of training/services including information on provider, location, length, etc) / Notes:
(supportive services needed, training schedule, referral contacts, etc)
Education Goal(s):
Occupational/Career Goal(s):
Work Readiness Goal (s):
Personal Goal(s):

ISS Summary/Comments:

I understand and agree to the service plan as described. I also understand that this plan does not constitute an entitlement to these services. I authorize my case manager and/or program staff to communicate pertinent information about me and my goals to any and all agencies, schools, and employers in order to assist me in meeting my training plan/goals.
Participant Signature / Case Manager Signature / Date
Date / Case Manager Initials / Participant Initials
1st ISS Review/Revision:
2nd ISS Review/Revision:
3rd ISS Review/Revision:
4th ISS Review/Revision:

Revised 7/1/16

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