INDIVIDUAL COMMUNITY SUPPORT PLAN

Client Name/Client # / Case Manager / Date of ICSP
Long-term goals/ dreams
Client Goals *
What is your goal in this life area? / Outcome Desired
How will you know when you have achieved this goal? / Services Needed and Responsibilities
What are the steps to reach this goal? Who does what? / Services Amount/ Frequency / Duration
When do you hope to achieve the goal? / Goal Status**
Life area
Life area
Life area
Does the client have any pending legal issues? Explain:
Has the client applied for all appropriate benefits? Explain:
Current medications (___see medications list in chart)
Standardized assessment process for side effects within the last year? __ yes ___no ___see medical chart
Diagnostic assessment / Last psychiatric contact / Last physical exam / Last dental exam
Client will access emergency services by:
Has client received a copy of written rights and responsibilities? __ yes ___no
The following signatures indicate agreement of the development and content of the ICSP
Client / Case Manager
Other / Mental Health Professional

*Life Area Codes: (1) Housing/Community Living (2) Vocational/Educational (3) Financial (4) Legal (5) Social

Support/Relationships (6) Leisure/Recreation (7) Health (8) Substance Abuse (9) Other areas.

** Status of Goal Codes: (1) New goal (2)Accomplished (3) Making Progress toward goal (4) Lack of progress toward goal (5) goal dropped

Your Rights and Responsibilities

CIVIL RIGHTS: You have the right to complain if you feel you have been discriminated against because of race, color, national origin, religion, sex, age, marital status of because of physical, mental or emotional disability. Complaints may be registered with:

Department of Human RightsDepartment of Human ServicesU.S. Department of Health and Human Services

500 BremerTowerHumanServicesBuildingOffice of Civil Rights – Region V

7th Place & Minnesota St444 Lafayette Rd105 W Adams, 16th floor

St Paul, MN55101St Paul, MN55155-3812Chicago, IL60603

RIGHT TO APPEAL: If you feel you have been unfairly denied or excluded from a service program, not given your choice of service, or told you must participate in a social service program, you may appeal for a Fair Hearing. An appeal form may be obtained from the county welfared agency or from the Appeals Office, Department of Public Welfare, CentennialOfficeBuilding, St Paul, MN55155.

RIGHT TO SERVICE: You have the right to be informed of all services, including income maintenance, available to you.

RIGHT TO PRIVACY: Information requested by this agency will be kept private. It may be reviewed by the county welfare agency, the Department of Public Welfare, or representatives of the federal government to determine your eligibility for federal social services funding, evaluate the quality of service you receive, or evaluate and develop legal mandates and policies. In the event our agency cannot provide the services you need, we may purchase these services for you from another agency. We will furnish information about your eligibility to receive purchased services to that agency.

RIGHT TO FAMILY PLANNING SERVICES: If you are an adult or minor receiving Public Assistance, you have the right to family planning services if you request these services. However, family planning services are not limited to only receiving Public Assistance.

RIGHT TO PROMPT ELIGIBILITY DETERMINATION: You have the right to have your eligibility determined within 30 days.

RIGHT TO ACCESS RECORDS: Your individual rights include the following:

  • The right to know what kind of information is being maintained and whether you are eth subject of the data
  • The right to be informed of the purpose for or intended us of, any information requested from you by a state government agency
  • The right to be informed whether or not you are legally required to supply requested data, and what consequences might arise if you refuse the request
  • The right to consent to accuracy of any data of which you are subject
  • The right to have disputed data withheld from disclosure except under conditions of demonstrated need – and then only if your statement of disagreement is included with the disclosed data.
  • The right to be shown at no cost any data of which you are the subject, unless the information is specifically classified as confidential by law (e.g., adoption records, foster care and day care licensing records; information directly related to a criminal investigation by a police agency; information of a medical and/or psychiatric nature used as a basis for diagnosis by a licensed physician; and in the case of child abuse, the name of the individual who reports alleged abuse shall be disclosed only (a) by the local welfare agency if the report is found to be unsubstantiated or (b) by the local welfare agency upon court order if the report is found to be substantiated).

IT IS YOUR RESPONSIBILITY:

  • To fully report circumstances affecting eligibility for social services
  • To provide proof of income to establish eligibility
  • To report any subsequent changes in circumstances
  • To cooperate with subsequent agency efforts to assess the appropriateness of eligibility process