Supervised Apartment Living Services (SAL)

Service Plan/Quarterly Progress Report/Discharge Summary

NAME OF CONTRACTOR:

SUPERVISED APARTMENT LIVING SERVICES

SERVICE PLAN/QUARTERLY PROGRESS REPORT/DISCHARGE SUMMARY REPORT

Service Plan

Service Plan Update/Quarterly Progress Report

Discharge Summary

Child Name / DHS/JCS Referring Worker
Date of Birth / Name, Phone, Email
Referral Date / Admission Date
State ID / Discharge Date
County Name & Number / Service Plan Date
DHS Service Area / SP/QPR Date
Next Report Due Date
Discharge Summary Date
Address of SAL Living Arrangement / ☐ Cluster ☐ Scattered
Date Report provided to DHS/JCS Referring Worker
Date Report provided to the Parent(s) or Guardian
Date Report reviewed with the Child
Date Report reviewed with the Parent(s) or Guardian
Date of Youth Transition Decision Making Meeting(s)
Caseworker Name, Phone, and Email
Education Specialist Name, Phone, and Email
Service Planning Conference
Date:
Present:

Service Plan Goals

Goal 1: / Projected Completion Date: / Completion Date:
Objective:
Objective:
Action Steps:
Progress:
Outcome:
Goal 2: / Projected Completion Date: / Completion Date:
Objective:
Objective:
Action Steps:
Progress:
Outcome:
Goal 3: / Projected Completion Date: / Completion Date:
Objective:
Objective:
Action Steps:
Progress:
Outcome:
Goal 4: / Projected Completion Date: / Completion Date:
Objective:
Objective:
Action Steps:
Progress:
Outcome:

Individual Child Development and Life Skills

Casey Life Skills Assessment
Date and Summary:
Reassessments:
Life Skills Plan
Plan:
Progress During Reporting Period and Recommended Changes to Plan:
Summary at Discharge:

Family and Community Connection

Family, Positive Support System, and Community Connections Engagement Plan
Plan:
Summarize Activity During Reporting Period and Recommended Changes to Plan:
Summary at Discharge:

Crisis Intervention and Stabilization

Individualized Crisis Intervention and Stabilization Plan
Plan:
Crisis Interventions During Reporting Period Recommended Changes to Plan:
Summary at Discharge:

Transition Planning

Individualized Transition Plan
Plan:
Progress During Reporting Period and Recommended Changes to Plan:
Summary at Discharge:

Education and Career Planning

Education and Career Plan
Plan:
Progress During Reporting Period and Recommended Changes to Plan:
Summary at Discharge:

Physical Health

Physical Health Summary and Identified Needs or Supports
Summary, Needs and Supports:
Supports Provided and Identified Needs During Reporting Period:
Summary at Discharge:

Mental and Behavioral Health and Clinical Support

Mental and Behavioral Health Summary and Identified Needs and Clinical Support
Summary, Needs and Supports:
Supports Provided and Identified Needs During Reporting Period:
Summary at Discharge:

Medication Management

Medication Management Plan
Plan:
Changes in Medication, Observation of the Child’s Response to Medication, and Recommended Changes to Plan:
Summary at Discharge:

Discharge Information

Discharge Information:
Caseworker Signature: / Date:
Supervisor Signature: / Date:

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