Youth’s Name ______

Community Care Plan Background Information (to be completed before meeting)

(FOR AGENCY USE ONLY)

County / Date / New Staffing Review Returning to Community
Presenting Staff / Agency
Contact Information
Youth: / Legal Custodian:
Address: / Relationship
City, State, Zip / Address:
Home phone: / City, State, Zip
Mobile phone: / Phone:
Date of birth/age: / Mobile Phone:
Race and gender: / Fax:
First Language: / First Language:
Resources
____RSDI/SSI = / $ / ___Child Support = / $ / ____Adoption Assistance = / $
____ IV-E= / $ / Other Resources:
Medicaid / Foster Care / Amerigroup / Peach State / Wellcare / #
Private Insurance / Company / #
Reason for LIPT Presentation
Education

School

/

Grade

IEP ___Yes ___No

/

If yes, area of eligibility:

School performance:

Form Approved 11-10-08

Agency involvement

DFCS involvement

DJJ involvement

/

Other agency involvement

/
Physical and Mental Health Needs

Medications (current only)

/

Dosage

Psychiatric/Psychological/Psychosexual/Forensic Evaluations (attach copies)

Date

/

Provider

/

Diagnoses

/

IQ

/

Recommendations

/ / / Full Verbal Performance / /
/ / / Full Verbal Performance / /
/ / / Full Verbal Performance / /
Placement History (attach additional pages as needed) /

Name

/

Begin Date

/

End Date

/

Reason for Discharge

/

Form Approved 11-10-08

Community Care Plan Background Information Instructions

Who should fill out the Community Care Plan Background Information form? The case manager from the lead agency is responsible for completing the background information prior to the LIPT meeting. The case manager must also be prepared to clearly and succinctly present a five-minute summary of the background information to the LIPT. Note: If you have information to add to the plan itself that will help the committee, go ahead and complete it prior to the meeting as well.

When should the Community Care Plan Background Information Form be completed? The background information should be completed before the LIPT meeting and sent to the chair at least two days in advance.

Where should the Community Care Plan Background Information be kept? The LIPT chair should keep a file copy, and the case manager from the lead agency should keep a copy for ongoing implementation and monitoring.

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