NC DIVISION OF MENTAL HEALTH, DEVELOPMENTAL DISABILITIES AND SUBSTANCE ABUSE SERVICES
PERSON-CENTERED PLANNING GUIDANCE DOCUMENT 2022
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assessed/discussed during plan development, but only those that the individual identifies that
they want to work on should be included in the plan.
Life Domains
Each life domain has a unique purpose that should provide a written picture of what is currently
happening, what the individual’s vision for a preferred life is for that area, and what the provider
is doing to support the individual to move closer to living their preferred life. These domains will
inform the development of a person-centered plan with targeted dates for accomplishment.
• Daily Life and Employment: What a person does as part of everyday life – school,
employment, volunteering, communication, routines, and life skills.
• Community Living: Where and how someone lives – housing and living options,
community access, transportation, home adaptation and modification.
• Safety and Security: Staying safe and secure – finances, emergencies, relationships,
neighborhood, well-being, decision making supports, legal rights, and issues.
• Healthy Living: Managing and accessing health care and staying well – medical, mental
health, behavioral, alcohol, tobacco and other drug use, medication management, life
span development, exercise, wellness, and nutrition.
• Social and Spirituality: Building/strengthening friendships and relationships, leisure
activities, personal networks, community inclusion, natural supports, cultural beliefs, and
faith community.
• Citizenship and Advocacy: Building valued roles, understanding personal rights,
making choices, sexual orientation, self-identification, setting goals, assuming
responsibility and driving how one’s own life is lived.
• Other Areas of Importance: To be utilized in those rare situations when what the
individual desires does not fit into one of the life domains listed above.
Action Plan
The Action Plan section of the PCP includes the individual’s long-term goal, short-term goals,
and interventions. Action steps and interventions should address various life domains, as
relevant to that individual’s goals, needs, and strengths. The providers approved for authorized
services are responsible for carrying out the plan and meeting the health and personal safety
needs of the individual. For each desired long-term goal, the Action Plan will include short-term
goal(s) as well as interventions. Below are definitions of each core component of the PCP as
well as tips for how to write them. In addition, the PCP template includes additional suggested
questions for directly soliciting the person’s input around each of these components.
• Long-Term Goal Development: Person-Centered Plans capture desired changes and
accomplishments. Long-term goals are what motivate people to engage in services and
make changes, are personal to that individual, often reflect one or more Life Domains,
and typically take time to achieve. Whenever possible, they are written as a brief quote
from the individual that captures what is most important to them in their vision of a
good/better life. Ideally, long-term goals are oriented toward quality-of-life priorities and
not only the management of health conditions and symptoms, e.g., I want to finish
school, get back to church, see my grandkids, get a car, etc.
• Short-Term Goals: help the person move closer to achieving their long-term goals. They