Permanency Plan

Court File Number
[TM1] / Branch Number
[TM2] / Name – Judge
[TM3]
Permanency Plan is: / [TM4]
Name – [TM5] (Last, First Middle)
[TM6] / Birth Date – [TM7]
[TM8]

MOTHER

/ FATHER
[TM9] / [TM10]

START_DYNAMIC_SECTION=attorneySection

Attorney:[TM11] / Attorney:[TM12]

END_DYNAMIC_SECTION=attorneySection

START_DYNAMIC_SECTION=legalGuardianSection

START_DYNAMIC_TABLE=legalGuardianTable

LEGAL GUARDIAN
[TM13]

END_DYNAMIC_TABLE=legalGuardianTable

END_DYNAMIC_SECTION=legalGuardianSection

START_DYNAMIC_SECTION=indianCustSection

START_DYNAMIC_TABLE=indianCustTable

INDIAN CUSTODIAN

[TM14]

END_DYNAMIC_TABLE=indianCustTable

END_DYNAMIC_SECTION=indianCustSection

CASE INFORMATION

Date – Form Filled Out
[TM15] / Name – Agency
[TM16]
Name – Worker
[TM17] / Name – Supervisor
[TM18]
Agency Case Number
[TM19] / Date – Next Permanency Review / Hearing Due
[TM20]
Name – District Attorney / Corporation Counsel
[TM21]

START_DYNAMIC_SECTION=caseNameSection

START_DYNAMIC_TABLE=caseNameTable

Name – [TM22]
[TM23]

END_DYNAMIC_TABLE=caseNameTable

END_DYNAMIC_SECTION=caseNameSection

CONSIDERATIONS FOR REVIEW / HEARING
1. / [TM24] Yes [TM25] No / Are there any Indian Child Welfare Act considerations with this [TM26]? START_DYNAMIC_SECTION=conForRvwSectionOneIf “Yes”, explain.END_DYNAMIC_SECTION=conForRvwSectionOne

START_DYNAMIC_SECTION=conForRvwExplainSection

[TM27]

END_DYNAMIC_SECTION=conForRvwExplainSection

2. / Provide a statement as to whether the [TM28]’s age and developmental level are sufficient for the court or review panel to consult with the [TM29] at the hearing or review.
[TM30]
3. / a. / Date of last face-to-face contact by the worker with the following:
[TM31]:[TM32]
Mother:[TM33]
Father:[TM34]
Out-of-home care provider:[TM35]
b. / Relevant information (e.g., location, who was in attendance, any interactions that were notable).
[TM36]
4. / Yes No[TM37] / Was the permanency plan developed in consultation with the child / youth? If “No”, explain. .
[TM38]
5. / Yes No[TM39] / Was the permanency plan developed in consultation with two other individuals selected by the child / youth who are not the child’s / youth’s caseworker or foster parent? If “No”, explain. If “Yes”, name the two individuals.
[TM40]
REMOVAL
1. / Explain the basis of the decision to place the [TM41] in custody. Include a narrative of the circumstances and why remaining in the home would be contrary to the [TM42]’s welfare; and the jurisdictional statute used as the basis.
[TM43]
2. / Identify and describe the actions taken and the services offered or provided by the agency to make reasonable efforts to prevent removal of the [TM44] from the home.
[TM45]

START_DYNAMIC_SECTION=ifTheChildIsIndian

If the child is an Indian child, describe the remedial services and rehabilitation programs offered in an effort to prevent the break up of the Indian child’s family.
[TM46]

END_DYNAMIC_SECTION=ifTheChildIsIndian

OUT-OF-HOME CARE PLACEMENT
1. / Date of removal: [TM47]
2. / Placement history
Begin Date / End Date / Placement Type / Out-of-Home Care Provider / Educational Stability Considerations

START_DYNAMIC_TABLE=plcmntHistory

[TM48] / [TM49] / [TM50] / [TM51] / [TM52]

END_DYNAMIC_TABLE=plcmntHistory

3. / Placement services history
Begin Date / End Date / Service Type / Service Provider

START_DYNAMIC_TABLE=servicesHistory

[TM53] / [TM54] / [TM55] / [TM56]

END_DYNAMIC_TABLE=servicesHistory

4. / Placement Considerations

START_DYNAMIC_SECTION=plcmntPreferencesSection

Placement Preferences
If the child is an Indian child, provide a statement as to whether the Indian child’s placement is in compliance with the order of the placement preference, and if the placement is not in compliance with that order, a statement as to whether there is good cause for departing from that order.
Placement Is / Placement Preference / Describe the action taken to comply with statutory placement preferences

START_DYNAMIC_TABLE=plcmntPreferences

[TM57] / [TM58] / [TM59]

END_DYNAMIC_TABLE=plcmntPreferences

END_DYNAMIC_SECTION=plcmntPreferencesSection

Consideration of relatives
[TM60] Yes [TM61] NoIs the [TM62] placed with a relative? If the [TM63] is NOT placed with a relative, describe why placement was not available, appropriate or safe. Identify which relatives have been sent notification of the [TM64]’s placement into out-of-home care in the box below.
Relative Contact Information / Relationship to [TM65] / Notification of Placement Sent / Placement Considered / Description of why placement was not available, appropriate or safe.

START_DYNAMIC_TABLE=conOfRelatives

[TM66] / [TM67] / [TM68] / [TM69] / [TM70]

END_DYNAMIC_TABLE=conOfRelatives

START_DYNAMIC_SECTION=relativeLocateSection

If a relative could not be located, describe subsequent / current efforts made to locate a relative.
[TM71]

END_DYNAMIC_SECTION=relativeLocateSection

Siblings
[TM72] Yes [TM73] NoAre all siblings that are in OHC placed together?
[TM74] Does not apply. [TM75] has no siblings or other siblings are not in placement.

START_DYNAMIC_SECTION=noSiblingsSection

If “No,” explain.
[TM76]

END_DYNAMIC_SECTION=noSiblingsSection

START_DYNAMIC_SECTION=locationPlacementSection

Location of Placement

START_DYNAMIC_SECTION=locationOfPlcmntSectionYes

[TM77] The [TM78]’s placement is within 60 miles of the [TM79]’s home and is in close proximity so as not to interfere with carrying out the permanency plan and maintaining the level of contact with the parents that is deemed appropriate.

END_DYNAMIC_SECTION=locationOfPlcmntSectionYes

START_DYNAMIC_SECTION=locationOfPlcmntSectionNo

[TM80] No setting is available within 60 miles of the [TM81]’s home that could respond to all the issues and needs that are part of this placement.
Describe: /
  • Why a placement within 60 miles of the [TM82]’s home is either unavailable or inappropriate; OR

  • Why a placement more than 60 miles from the [TM83]’s home is in the [TM84]’s best interest.

[TM85]

END_DYNAMIC_SECTION=locationOfPlcmntSectionNo

END_DYNAMIC_SECTION=locationPlacementSection

5. / Reasonable and Prudent Parenting Considerations
Yes No[TM86] / Did the agency provide information to the out-of-home care provider for consideration in making reasonable and prudent parenting decisions specific to the child / youth? If “No”, explain.
[TM87]
Describe the efforts made by the agency to ensure that the child / youth has regular, ongoing opportunities to engage in age or developmentally appropriate activities determined in accordance with the reasonable and prudent parent standard in the out-of-home care placement which includes consulting with the child/youth in an age appropriate manner.
[TM88]
6. / [TM89] Yes [TM90] No / Did the court order indicate a transitional placement? START_DYNAMIC_SECTION=didTheCourtSectionIf “Yes”, describe in detail including anticipated date of the placement change.
[TM91]
Name – New Placement
[TM92]
Address – New Placement (Street, City, State, Zip Code)
[TM93]END_DYNAMIC_SECTION=didTheCourtSection
7. / [TM94] Yes [TM95] No / Does the agency anticipate a placement change? START_DYNAMIC_SECTION=doesTheAgncySectionIf “Yes,” describe in detail including anticipated date of the placement change.
[TM96]
Name – New Placement
[TM97]
Address – New Placement (Street, City, State, Zip Code)
[TM98]END_DYNAMIC_SECTION=doesTheAgncySection

START_DYNAMIC_SECTION=cseSection

8. / Confirming Safe Environments (Safety of Placement)

START_DYNAMIC_SECTION=cseCansSection

Date of Child and Adolescent Needs and Strengths (CANS)
[TM99]
Child’s Assessed Level of Need (LON)
[TM100] / Provider’s Level of Care (LOC)
[TM101]
Child / Provider Match
[TM102]
Describe below.
[TM103]

END_DYNAMIC_SECTION=cseCansSection

a. / Placement Danger Threats

START_DYNAMIC_SECTION=plcmDangerThreat1

[TM104]

END_DYNAMIC_SECTION=plcmDangerThreat1

START_DYNAMIC_SECTION=plcmDangerThreat2

b. / If a Placement Danger Threat is selected above, please answer the following question.
[TM105] Yes [TM106] No [TM107] N/A / The court continued placement despite an identified Placement Danger Threat. START_DYNAMIC_SECTION=pPlcmntSectionIf “Yes”, describe the plan to ensure a safe environment for the child.
[TM108]END_DYNAMIC_SECTION=pPlcmntSection
c. / [TM109] Yes [TM110] No / Does the placement provider need to acquire any special skills or knowledge to meet the needs of the child and handle the behaviors of the child in a safe manner? START_DYNAMIC_SECTION=pPlcmntSectionOneIf “Yes”, describe.
[TM111]END_DYNAMIC_SECTION=pPlcmntSectionOne

START_DYNAMIC_SECTION=riskManagementSection

d. / [TM112]

END_DYNAMIC_SECTION=riskManagementSection

END_DYNAMIC_SECTION=cseSection

PERMANENCY
1. / The agency’s determination of whether to engage in concurrent planning indicates:
[TM113]
2. / [TM114] Yes [TM115] No / Despite the agency’s determination to engage in concurrent planning, has the court determined that having a concurrent permanency goal is not appropriate? START_DYNAMIC_SECTION=agencyDateSectionDate: [TM116]END_DYNAMIC_SECTION=agencyDateSection
3. / a. / [TM117]’s [TM118] permanence and, if applicable, concurrent permanence goal of record.
Permanence Goal: / [TM119]

START_DYNAMIC_SECTION=prmncyReunificationSection

Reunification
Rationale for choosing this goal:
[TM120]
Efforts made to achieve the goal, including, if appropriate, through an out-of-state placement:
[TM121]
Conditions to reunify safely.
[TM122]

END_DYNAMIC_SECTION=prmncyReunificationSection

START_DYNAMIC_SECTION=prmncyAdoptionSection

Adoption
Rationale for choosing this goal:
[TM123]
Efforts made to achieve the goal, including, if appropriate, through an out-of-state placement:
[TM124]
[TM125] Yes [TM126] No / Has an Adoption Referral been made?
If an adoption worker has been assigned, list below his or her name and the date assigned.
Name – Adoption Worker
[TM127] / Date Assigned
[TM128]
[TM129] Yes [TM130] No / [TM131] is placed with an adoptive resource.
[TM132] Yes [TM133] No / Adoptive resource needs to be identified.
[TM134] Yes [TM135] No / Barriers to adoption – If “Yes”, describe.
[TM136]

END_DYNAMIC_SECTION=prmncyAdoptionSection

START_DYNAMIC_SECTION=prmncyGrdianSection

Guardianship
Rationale for choosing this goal:
[TM137]
[TM138] Yes [TM139] No / [TM140] is with resource that will become permanent guardian.
Efforts made to achieve the goal, including, if appropriate, through an out-of-state placement.
[TM141]
[TM142] Yes [TM143] No / Has an eligibility determination been made for Subsidized Guardianship?

START_DYNAMIC_SECTION=prmncySGSection

If “Yes”, what is the eligibility determination for the [TM144] and proposed guardian and supporting rationale? [TM145]

END_DYNAMIC_SECTION=prmncySGSection

END_DYNAMIC_SECTION=prmncyGrdianSection

START_DYNAMIC_SECTION=prmncyPlcmntSection

Placement with a Fit and Willing Relative
Rationale for choosing this goal:
[TM146]
Efforts made to achieve the goal, including, if appropriate, through an out-of-state placement.
[TM147]

END_DYNAMIC_SECTION=prmncyPlcmntSection

START_DYNAMIC_SECTION=prmncyOPPLASection

Other Planned Permanent Living Arrangement (OPPLA) - [TM148]
Identify the name of the adult(s) committed to a long-term relationship with the [TM149].
[TM150]
Describe the compelling reason why it would not be in the best interests of the [TM151] to return the [TM152] to his or her home or to place the [TM153] for adoption, with a guardian, or with a fit and willing relative and the efforts made to achieve that goal, if appropriate, through an out-of-state placement.
[TM154]
Describe the intensive and ongoing efforts made by the agency, including searching social media, to return the child / youth to the child’s / youth’s home or to place the child / youth for adoption, with a guardian, or with a fit and willing relative and that those efforts have proved unsuccessful.
[TM155]
Rationale for choosing this goal:
[TM156]

END_DYNAMIC_SECTION=prmncyOPPLASection

START_DYNAMIC_SECTION=concurrentGoalSection

Concurrent Goal: / [TM157]

END_DYNAMIC_SECTION=concurrentGoalSection

START_DYNAMIC_SECTION=concurReunificationSection

Reunification
Rationale for choosing this goal:
[TM158]
Efforts made to achieve the goal, including, if appropriate, through an out-of-state placement:
[TM159]
Conditions to reunify safely.
[TM160]

END_DYNAMIC_SECTION=concurReunificationSection

START_DYNAMIC_SECTION=concurAdoptionSection

Adoption
Rationale for choosing this goal:
[TM161]
Efforts made to achieve the goal, including, if appropriate, through an out-of-state placement:
[TM162]
[TM163] Yes [TM164] No / Has an Adoption Referral been made?
If an adoption worker has been assigned, list below his or her name and the date assigned.
Name – Adoption Worker
[TM165] / Date Assigned
[TM166]
[TM167] Yes [TM168] No / [TM169] is placed with an adoptive resource.
[TM170] Yes [TM171] No / Adoptive resource needs to be identified.
[TM172] Yes [TM173] No / Barriers to adoption – If “Yes”, describe.
[TM174]

END_DYNAMIC_SECTION=concurAdoptionSection

START_DYNAMIC_SECTION=concurGrdianSection

Guardianship
Rationale for choosing this goal:
[TM175]
[TM176] Yes [TM177] No / [TM178] is with resource that will become permanent guardian.
Efforts made to achieve the goal, including, if appropriate, through an out-of-state placement.
[TM179]
[TM180] Yes [TM181] No / Has an eligibility determination been made for Subsidized Guardianship?

START_DYNAMIC_SECTION=concurSGSection

If “Yes”, what is the eligibility determination for the [TM182] and proposed guardian and supporting rationale? [TM183]

END_DYNAMIC_SECTION=concurSGSection

END_DYNAMIC_SECTION=concurGrdianSection

START_DYNAMIC_SECTION=concurPlcmntSection

Placement with a Fit and Willing Relative
Rationale for choosing this goal:
[TM184]
Efforts made to achieve the goal, including, if appropriate, through an out-of-state placement.
[TM185]

END_DYNAMIC_SECTION=concurPlcmntSection

START_DYNAMIC_SECTION=concurOPPLASection

Other Planned Permanent Living Arrangement (OPPLA) - [TM186]
Identify the name of the adult(s) committed to a long-term relationship with the [TM187].
[TM188]
Describe the compelling reason why it would not be in the best interests of the [TM189] to return the [TM190] to his or her home or to place the [TM191] for adoption, with a guardian, or with a fit and willing relative and the efforts made to achieve that goal, if appropriate, through an out-of-state placement.
[TM192]
Describe the intensive and ongoing efforts made by the agency, including searching social media, to return the child / youth to the child’s / youth’s home or to place the child / youth for adoption, with a guardian, or with a fit and willing relative and that those efforts have proved unsuccessful.
[TM193]
Rationale for choosing this goal:
[TM194]

END_DYNAMIC_SECTION=concurOPPLASection

START_DYNAMIC_SECTION=descPrmHideCr

b. / [TM195]’s [TM196] permanence and, if applicable, concurrent permanence goal.
Permanence Goal: / [TM197]

START_DYNAMIC_SECTION=concurGoalSection

Concurrent Goal: / [TM198]

END_DYNAMIC_SECTION=concurGoalSectione

Describe rationale for the [TM199]'s goal(s)
[TM200]

END_DYNAMIC_SECTION=descPrmHideCr

4. / Anticipated date the permanence goal will be achieved: [TM201]
5. / [TM202]Yes [TM203] No / a. / Has the court made a finding that reasonable efforts to prevent removal or safely return to home are not required?

START_DYNAMIC_SECTION=dateOfCrtFilingSection

Date of court finding: [TM204]

END_DYNAMIC_SECTION=dateOfCrtFilingSection

b. / Termination of Parental Rights
Date referred to the district attorney's / corporation counsel's office: [TM205]
Date TPR was filed: / [TM206]

START_DYNAMIC_SECTION=asfaSection

c. / Adoption Safe Families Act Exceptions: State the reason why TPR is not being pursued at 15 of 22 months. This is a point in time determination made by the agency and shall not be modified once established. This exception does not prohibit the agency from pursuing a TPR at a later date, if it is deemed in the [TM207]’s best interests.
Date of ASFA Exception: [TM208]
[TM209] / Child is placed with a fit and willing relative.

START_DYNAMIC_SECTION=asfaQuestionOne

[TM210]

END_DYNAMIC_SECTION=asfaQuestionOne

[TM211] / Compelling reason(s) why termination of parental rights is not in the child’s best interest.

START_DYNAMIC_SECTION=asfaQuestionTwo

[TM212]

END_DYNAMIC_SECTION=asfaQuestionTwo

[TM213] / Reasonable efforts to safely return the child to his or her home have not been made.

START_DYNAMIC_SECTION=asfaQuestionThree

[TM214]

END_DYNAMIC_SECTION=asfaQuestionThree

[TM215] / Grounds for involuntary TPR do not exist.

START_DYNAMIC_SECTION=asfaQuestionFour

[TM216]

END_DYNAMIC_SECTION=asfaQuestionFour

END_DYNAMIC_SECTION=asfaSection

6. / a. / Date of latest Permanency Review: [TM217]
b. / Permanency Plan Review Report provided to the court on Date: [TM218]
c. / The panel found that reasonable or, in the case of an Indian child, active efforts to achieve the goal(s) of the permanency plan were:
[TM219]
d. / As a result of the review, were recommendations made that:
[TM220] Yes [TM221] No Conflict with the court order?
[TM222] Yes [TM223] No Provide for additional services not specified in the court order?
[TM224] Yes [TM225] No Otherwise require a modification of the court order or permanency plan?
[TM226] Yes [TM227] No Was a revision to the court order requested? START_DYNAMIC_SECTION=concurSevenSectionIf “Yes,” describe the outcome of the hearing.
[TM228]END_DYNAMIC_SECTION=concurSevenSection
e. / Date of latest Permanency Hearing: [TM229]

START_DYNAMIC_SECTION=caseInfoSummarySection

f. / Summarize significant case information, developments or events since the latest Permanency Review / Permanency Hearing or updates since the initial plan was created if this is the first Permanency Review / Permanency Hearing.
[TM230]

END_DYNAMIC_SECTION=caseInfoSummarySection

WELL-BEING
1. / [TM231]'s Health Summary
a. / Check each item below that applies.
[TM232] / [TM233] has chronic physical, mental or emotional issues.START_DYNAMIC_SECTION=hasChronicSection Describe in detail. [TM234]END_DYNAMIC_SECTION=hasChronicSection
[TM235] / [TM236] has had a hospitalization, surgery, emergency medical need, or significant illness in the last six months.START_DYNAMIC_SECTION=hasHospitalSection Describe in detail.
[TM237]END_DYNAMIC_SECTION=hasHospitalSection
[TM238]Yes [TM239]NoIs the [TM240] prescribed medication?If “Yes”, provide the following information on all prescription medications:

START_DYNAMIC_SECTION=medicationSection

Name of Medication / Dosage / Frequency /

Psychotropic

/ Reason Medication is Prescribed / Length Prescribed / Physician / Address

START_DYNAMIC_TABLE=medicationHistory

[TM241] / [TM242] / [TM243] / [TM244] / [TM245] / [TM246]

END_DYNAMIC_TABLE=medicationHistory

END_DYNAMIC_SECTION=medicationSection

b. / Provide the name and address of current health care providers.

START_DYNAMIC_SECTION=currentHlthPrvdSection

START_DYNAMIC_TABLE=currentHlthProviders

[TM247] / [TM248]

END_DYNAMIC_TABLE=currentHlthProviders

END_DYNAMIC_SECTION=currentHlthPrvdSection

c. / Immunization Information
[TM249]Yes [TM250]No[TM251]’s immunizations are up-to-date. START_DYNAMIC_SECTION=immunizationYesSectionIf “Yes,” as of [TM252].END_DYNAMIC_SECTION=immunizationYesSection

START_DYNAMIC_SECTION=immunizationNotSection

If "No," describe why immunizations are not up-to-date and how and when this will be rectified.
[TM253]

END_DYNAMIC_SECTION=immunizationNotSection

START_DYNAMIC_SECTION=immunizationSection

d. / Immunization Record
[TM254]'s immunization record listed below.
Immunization / Date(s) Administered

START_DYNAMIC_TABLE=immunizationHistory

[TM255] / [TM256]

END_DYNAMIC_TABLE=immunizationHistory

END_DYNAMIC_SECTION=immunizationSection

2. / [TM257]'s Educational Summary

START_DYNAMIC_SECTION=educationSection

a. / [TM258]

END_DYNAMIC_SECTION=educationSection

b. / Provide name and address of current school or special education providers.
[TM259]
c. / Describe current academic performance. Include grade level, special achievements and current educational difficulty(s). Indicate the date and source of your information.
[TM260]
Current or most recent grade level: [TM261]
[TM262] Yes [TM263] No / Is this grade level where the [TM264] should be (do not include a child who voluntarily begins kindergarten at age 6)? If no, what is the primary reason for the [TM265] not being on grade level?

START_DYNAMIC_SECTION=mostRecentGrdLevelSection

[TM266]

END_DYNAMIC_SECTION=mostRecentGrdLevelSection

d. / [TM267] Yes [TM268] No [TM269] N/A / Is the most recent grade report attached?

START_DYNAMIC_SECTION=mostRecentGrdReportSection

If "No," a request for school records was made to [TM270] on [TM271].

END_DYNAMIC_SECTION=mostRecentGrdReportSection

3. / Visitation / Family Interaction
Describe family interaction plans.

START_DYNAMIC_SECTION=nonSacwisFmlySection

[TM272]

END_DYNAMIC_SECTION=nonSacwisFmlySection

START_DYNAMIC_SECTION=sacwisFmlySection

a.

/

Parent / Caregiver 1: [TM273]

START_DYNAMIC_SECTION=parentCrgSectionA

Minimum Level Required: [TM274] / Frequency: [TM275]
Supervised by: [TM276]
Least Restrictive Location Permissible: [TM277]

END_DYNAMIC_SECTION=parentCrgSectionA

b.

/

Parent / Caregiver 2: [TM278]

START_DYNAMIC_SECTION=parentCrgSectionB

Minimum Level Required: [TM279] / Frequency: [TM280]
Supervised by: [TM281]
Least Restrictive Location Permissible: [TM282]

END_DYNAMIC_SECTION=parentCrgSectionB

c. /
Description of Sibling Interaction Plan
When siblings are not seeing each other as part of the family interaction plan, a sibling interaction plan is necessary. Describe how, when and at what frequency sibling interactions will occur.
[TM283]

END_DYNAMIC_SECTION=sacwisFmlySection

4. / Independent Living (IL) Services
A youth is eligible for Independent Living Services when in Out-of-Home Care for six months after age of 14.
Youth is: [TM284] Eligible [TM285] Not EligibleSTART_DYNAMIC_SECTION=ilDateSection
Date youth became eligible for Independent Living Services: [TM286]END_DYNAMIC_SECTION=ilDateSection
Yes No[TM287] / Did the child / youth receive the Handbook for Youth in Foster Care which describes the rights listed in § 48.38(4)(h)7. / § 938.38(4)(h)7.? Date received: [TM288]

START_DYNAMIC_SECTION=currILServicesSection

Current Services / Activities

START_DYNAMIC_TABLE=currentILServices

Independent Living Service Category
[TM289]
Service / Activity
[TM290] / Begin Date
[TM291]
Provider / Responsible Person
[TM292]
Specifically Explain Goal / Service / Activity
[TM293]

END_DYNAMIC_TABLE=currentILServices

END_DYNAMIC_SECTION=currILServicesSection

START_DYNAMIC_SECTION=histILServicesSection

Historical Services / Activities

START_DYNAMIC_TABLE=histILServices

Independent Living Service Category
[TM294]
Service / Activity
[TM295] / Begin Date
[TM296] / End Date
[TM297]
Provider / Responsible Person
[TM298]
Specifically Explain Goal / Service / Activity
[TM299]

END_DYNAMIC_TABLE=histILServices

END_DYNAMIC_SECTION=histILServicesSection

START_DYNAMIC_SECTION=iltdSection

Transition to Discharge Plan
Housing
Goal: Safe and secure living environment upon leaving care.
Anticipated location youth will transition to: [TM300]
Address Youth Will Transition To
[TM301]
Housing Resource (if applicable)
[TM302] / Telephone Number at Housing Resource
[TM303]
Description of Activities to Achieve Goal
[TM304]
Provider / Responsible Person
[TM305]
Date to be Completed
[TM306] / [TM307] Yes [TM308] No Goal achieved? / Date Goal Achieved
[TM309]
Alternate location youth will transition to: [TM310]
Address Youth Will Transition To
[TM311]
Housing Resource (if applicable)
[TM312] / Telephone Number at Housing Resource
[TM313]
Description of Activities to Achieve Goal
[TM314]
Provider / Responsible Person
[TM315]
Date to be Completed
[TM316] / [TM317] Yes [TM318] No Goal achieved? / Date Goal Achieved
[TM319]
Health
GOAL 1: Obtainment of private insurance or Badger Care Plus (Youth Exiting Out-of-Home Care):[TM320]
Description of Activities to Achieve Goal
[TM321]
Provider / Responsible Person
[TM322]
Date to be Completed
[TM323] / [TM324] Yes [TM325] No Goal achieved? / Date Goal Achieved
[TM326]
GOAL 2: Educate youth regarding the importance of designating another individual to make health care treatment decisions on his / her behalf.
Description of Activities to Achieve Goal
[TM327]
Provider / Responsible Person
[TM328]
Date to be Completed
[TM329] / [TM330] Yes [TM331] No Goal achieved? / Date Goal Achieved
[TM332]
Education (secondary / post-secondary)
GOAL 1: Completion of high school (GED / HSED).
Description of Activities to Achieve Goal
[TM333]
Provider / Responsible Person
[TM334]
Anticipated Date of High School Diploma or GED / HSED[TM335] / [TM336] Yes [TM337] No Goal achieved? / Date Goal Achieved
[TM338]
GOAL 2: Exploration / enrollment in post-secondary education program.
Description of Activities to Achieve Goal
[TM339]
Provider / Responsible Person
[TM340]
Anticipated Date of Post-secondary Enrollment
(If N/A provide explanation)
[TM341] / [TM342] Yes [TM343] No Goal achieved? / Date Goal Achieved
[TM344]
GOAL 3: Financial Assistance Explored and / or Obtained
Description of Activities to Achieve Goal
[TM345]
Provider / Responsible Person
[TM346]
Date to be Completed
[TM347] / [TM348] Yes [TM349] No Goal achieved? / Date Goal Achieved
[TM350]
Mentors and / or Other Supportive Adults Identified
Goal: Explore and identify opportunities for mentoring and adult support after leaving foster care. Identify at least three individuals.
Description of Activities to Achieve Goal
[TM351]
Provider / Responsible Person
[TM352]
Date to be Completed
[TM353] / [TM354] Yes [TM355] No Goal achieved? / Date Goal Achieved
[TM356]
Supportive adults, other than helping professionals, who are available and willing to work with the youth as he / she transitions toward and through his / her discharge to self-sufficiency and beyond.
Name / Relationship / Contact Information

START_DYNAMIC_TABLE=iltdContactsInfo