Practical guide · Person-centered planning

ISP goals for adults with disabilities: examples and how to write them.

Published 2026-10-28 · Updated 2026-10-29

An individual support plan (ISP), also called a person-centered plan or individual service plan, sets out what matters to the person, the support they need and the goals they choose. Good goals are the person's own, specific and measurable, so staff know what to support and everyone can see progress. The examples use invented people, and your state's form and terms may differ.

Your people verify facts, correct AI drafts, sign records and approve consequential actions.

Read the guide ↓

30 days free · Then $20 USD per person supported per month.

$0 setup for system initialization · Month-to-month · No long-term contract

Migration scope and costs are separately agreed.

Key points

The short version.

Start with the person's own words.
Separate the outcome, the measurable goal and the support strategy.
Say what, how often, with what support and by when.
Record work on each goal in daily notes.
Review at least every 12 months and when things change.
Never write a rights restriction as a goal.

01 · Person-centered planning

Start with what the person wants.

Federal rules for Medicaid HCBS waivers (42 CFR 441.301(c)) require the planning process to be led by the person, include people they choose, offer informed choices and happen at times and places convenient to them. The plan must include individually identified goals and desired outcomes, reflect the person's strengths and preferences, and be written in plain language the person can understand.

So a goal starts in the person's own words: "I want a job working with animals," "I want to cook dinner for my sister," "I want to take the bus to church by myself." The planning team's job is to turn that into steps and support, not to choose the goal for them.

Ask what the person wants more of, less of and to learn.
Write the goal in a way the person would recognize as theirs.
Note who the person wants involved.

02 · Person-centered planning

Know the difference between an outcome, a goal and a support strategy.

Plans use different words, but most separate three things. The outcome is what the person wants in their life. The goal or objective is a measurable step toward it. The support strategy is what staff do to help.

Outcome: "Dana wants a paid job at an animal shelter." Goal: "Dana will volunteer at the county animal shelter two mornings a week for three months, completing her task list with no more than one verbal prompt per shift." Support strategy: "Staff ride the bus with Dana for the first four weeks, then meet her at the shelter; staff review her picture task list with her before each shift."

03 · Person-centered planning

Make every goal measurable.

A measurable goal says what the person will do, how often or how well, with what level of support, and by when. Many teams use the SMART test: specific, measurable, achievable, relevant to the person and time-bound.

Weak: "Marcus will improve his cooking skills." Stronger: "By March 31, Marcus will make a breakfast of his choice three mornings a week using his picture recipe, with no more than two verbal prompts, as recorded in daily notes."

Name the action the person will take.
Say how it is measured: times per week, percent of opportunities or prompt level.
Set a review date.
Say where progress is recorded.

04 · Person-centered planning

Example goals by life area.

These examples use invented people. Adjust them to the person's own priorities, abilities and supports.

Employment: "Lena will apply for two jobs she chooses each month, using a resume she updates with her job coach, until she is hired."
Home and daily living: "Marcus will do his own laundry each Saturday, sorting, washing and folding with no more than one gestural prompt, for 10 of 12 weeks."
Health: "Ruth will take her evening medications at the kitchen counter and tell staff when each one is taken, with verbal reminders only, on 90% of evenings."
Community: "James will ride the bus to his church and back with staff following in a car, then on his own, within six months."
Relationships: "Tia will call or video-chat with her brother every Sunday, starting the call herself on the tablet."
Money: "Andre will pay for his own purchases at the store, counting bills and waiting for change, on four outings a month."
Communication and self-advocacy: "Sam will use his communication device to choose his weekend activity from three options every Friday."

05 · Person-centered planning

Connect each goal to daily notes.

A goal is only as useful as the record of working on it. Each progress note should name the goal, the support given, the prompt level and how the person responded, so the next review can show real progress instead of a guess.

If staff cannot tell from the goal what to do or what to record, rewrite the goal or the support strategy before the next shift, not at the annual review.

06 · Person-centered planning

Review and change goals.

The same federal rules require the plan to be reviewed and revised at least every 12 months, when the person's circumstances or needs change significantly, and when the person asks.

Look at the data at each review. A goal met should be replaced by the next step the person wants. A goal with no progress usually needs a different support strategy, or it may not be what the person wants anymore. Ask them.

07 · Person-centered planning

Restrictions are not goals.

Limiting a person's rights in a provider-controlled home, such as access to food, visitors, privacy or a lockable door, is not a goal or a house rule. Under the federal HCBS settings rule, a modification must be justified in the plan with eight things documented.

A specific, individualized assessed need.
Positive interventions and supports used first.
Less intrusive methods tried that did not work.
A clear description of the condition, proportionate to the need.
Regular collection and review of data on whether it works.
Time limits for periodic review.
The person's informed consent.
An assurance that it will cause no harm.

08 · Person-centered planning

How do you write ISP goals for people with high support needs?

Write goals around what matters to the person and the part of an activity they can do or control, even when staff do most of the physical work. A goal does not have to be about independence. It can be about choice, participation, comfort, communication or relationships.

Learn what the person likes from how they respond, and from family and staff who know them well. Notice the activities that bring a smile, a reach or a calm body, and build goals that give the person more of those and more control over them. Write down how the person shows a choice, so every staff member reads it the same way.

Participation: "Eli will hold his cup and guide it to his mouth at breakfast, with hand-under-hand support, on 5 of 7 mornings."
Choice: "Rosa will choose between two shirts each morning by looking at or reaching toward one, on 4 of 5 mornings."
Comfort: "Ben will take part in a 10-minute hand massage, with a lotion he picks by smell, three evenings a week."
Community: "Ana will go to the library music hour she enjoys twice a month, choosing her seat by pointing."

09 · Person-centered planning

What are examples of communication goals in an ISP?

Communication goals help the person tell others what they want, need, like and don't like, in whatever form works for them: speech, signs, pictures, gestures or a device. A good communication goal names the method, the situation and how progress is measured.

Involve a speech-language professional when the person uses, or might benefit from, an augmentative communication system, and make sure every staff member knows how the person's system works. A device left in a closet cannot support any goal.

Requesting: "Jo will ask for a break by handing staff her break card during chores, on 4 of 5 opportunities."
Refusing: "Max will sign 'stop' when he wants to end an activity, and staff will stop each time he does."
Greeting: "Lia will greet her day program peers with her device's greeting button when she arrives, three days a week."
Sharing news: "Omar will show his sister photos from his week on his tablet during their Sunday call."
Health: "Nia will point to her body chart to show where it hurts when staff ask, during monthly practice and whenever she seems unwell."

10 · Person-centered planning

How do you measure progress on ISP goals?

Choose one measurement method that fits the goal and use it the same way every time, so the numbers at review mean something. The method should be simple enough for every DSP to record during a normal shift.

Look at the data monthly, or at the interval your state or agency sets, not only at the annual review. A simple count or graph over time shows whether support is working far better than a stack of notes. If staff record the same goal in different ways, fix the goal's wording or the training.

Frequency: how many times the person did something, such as calls made or bus trips taken.
Percent of opportunities: how often the person did it out of the times it was offered.
Prompt level: the least help the person needed, using the levels the plan defines.
Duration: how long the person took part, such as minutes of exercise.
Task steps: how many steps of a written routine the person completed.
The person's own view: whether they say or show that they like it and want to keep going.

11 · Person-centered planning

What is the difference between a goal and a preference?

A preference is something the person likes or wants that staff respect every day; a goal is something the person wants to work toward, with a measurable step and support. "Leah likes to sleep in on weekends" is a preference. "Leah will set her own alarm and get ready for work on time on weekdays" is a goal.

The plan must reflect the person's strengths and preferences, so preferences belong in it even though they are not measured like goals. Turning a preference into a goal, such as "Leah will sleep in on weekends," adds data work without helping her. Turning a goal into a vague preference loses the support she asked for.

A quick check: if staff only need to know it and respect it, it is a preference. If staff need to teach, prompt or record progress, it is a goal.

12 · Person-centered planning

What do poorly written ISP goals look like, and how do you rewrite them?

Poor goals are usually vague, written for staff convenience, or about what the person should stop doing instead of what they want. Rewriting them around the person's own words and a clear measure fixes most problems.

The last weak example is a support strategy, not a goal: it describes what staff do. Keep it in the plan as the support, and write the goal about what Ray does.

Weak: "Chris will be compliant with his schedule." Rewritten: "Chris will use his picture schedule to choose the order of his three morning tasks, on 4 of 5 weekdays."
Weak: "Pat will have no behaviors." Rewritten: "Pat will tell staff 'I need space' and go to her room when she feels upset, with one verbal reminder, on 3 of 4 occasions."
Weak: "Gina will socialize more." Rewritten: "Gina will invite a friend she chooses to lunch twice a month, making the call herself with staff nearby."
Weak: "Staff will assist Ray with hygiene." Rewritten: "Ray will brush his teeth for two minutes using his timer, with no more than one gestural prompt, each evening."

13 · Person-centered planning

Keep goals where staff document.

Goals written in a binder that staff never see do not get worked on. Put the current goals and support strategies where staff write their notes, so each note can name the goal it supports.

In LunahUP, the person's plan context and goals stay with their record, within reach of the staff documenting support. Staff provide the facts for each note and check any AI-prepared wording before they sign.

Questions people ask

Short answers.

What is the difference between an ISP and a person-centered plan?

States and agencies use different names, such as ISP, individual service plan or person-centered support plan, for the plan required in Medicaid HCBS. The idea is the same: the person's goals, needs and supports in one plan.

Who writes ISP goals?

The person leads, with the planning team they choose. A case manager or support coordinator usually facilitates. Federal conflict-of-interest rules generally keep providers of the person's services from developing the plan.

How many goals should an ISP have?

There is no federal number. Focus on a manageable set the person cares about and staff can actually support and record. Your state's form may set its own expectations.

How often are ISP goals reviewed?

Federal HCBS rules require review at least every 12 months, when needs or circumstances change significantly, and when the person asks. Your state may require more frequent progress reviews.

Can a goal be to maintain a skill?

Yes, if the person wants it. Keeping a job, staying healthy or keeping a skill can be a real outcome. Write how it will be measured, just like any other goal.

Can an ISP goal be about health?

Yes, if the person wants it and it is written as something they do, such as choosing a walk three times a week or telling staff when they feel unwell. Treatment decisions belong to the person and their clinicians; the plan records the support they need.

What if the person does not want any goals?

Respect that and find out why. Ask what the person wants more or less of in their life, in a way that suits how they communicate. A goal can be small and about something they enjoy. Record their choice and revisit it when they ask.

Should ISP goals use percentages?

Only when the percentage is easy to record and means something. Percent of opportunities works when staff offer the activity often and track each offer. For a goal that happens once a week, a simple count, such as 3 of 4 Sundays, is usually clearer.

Sources

Check the official source.

Requirements change and differ by state. Confirm current rules with your state agencies and payers.

Keep the work connected

Related LunahUP workflows.

Start with one recurring task

Bring the goal your staff struggle to document.

Inspect a fictional person record with plan goals, and a note prepared from staff facts against one of them.

Book a 30-minute compliance demo

Use sample data. No patient or employee records needed for the demo. Booking does not create an account or start billing.