Case Plan
Court File Number[TM1] / Branch Number
[TM2] / Name – Judge
[TM3]
Case Name: / [TM4] / Agency Case Number:[TM5]
Name – [TM6] (Last, First Middle)
[TM7] / Birth Date – [TM8]
[TM9]
Date – Case Plan
[TM10] / Name – Agency
[TM11]
Name – Worker
[TM12] / Name – Supervisor
[TM13]
Date – Next Review / Hearing
[TM14]
OUT-OF-HOME CARE PLACEMENT SERVICE HISTORY: [TM15]
Begin Date / End Date /
Service Type
/ Service Provider[TM16] / [TM17] / [TM18] / [TM19]
WELL-BEING: [TM20]
1. / [TM21]'s Health Summary
a. / Check each item below that applies.
[TM22] / [TM23] has chronic physical, mental or emotional issues. Describe in detail. [TM24]
[TM25] / [TM26] has had a hospitalization, surgery, emergency medical need, or significant illness in the last six months. Describe in detail.
[TM27]
[TM28]Yes [TM29]NoIs the [TM30] prescribed medication?If “Yes”, provide the following information on all prescription medications:
Name of Medication / Dosage / Frequency /
Psychotropic
/ Reason Medication is Prescribed / Length Prescribed / Physician / Address[TM31] / [TM32] / [TM33] / [TM34] / [TM35] / [TM36]
b. / Provide the name and address of current health care providers.
[TM37] / [TM38]
c. / Immunization Information
[TM39]Yes [TM40]No[TM41]’s immunizations are up-to-date. If “Yes,” as of [TM42].
If "No," describe why immunizations are not up-to-date and how and when this will be rectified.
[TM43]
d. / Immunization Record
[TM44]
Immunization / Date(s) Administered
[TM45] / [TM46]
2. / [TM47]'s Educational Summary
a. / [TM48]
b. / Provide name and address of current school or special education providers.
[TM49]
c. / Describe current academic performance. Include grade level, special achievements and current educational difficulty(s). Indicate the date and source of your information.
[TM50]
Current or most recent grade level: [TM51]
[TM52]Yes [TM53]NoIs this grade level where the [TM54] should be (do not include a child who voluntarily begins kindergarten at age 6)? If no, what is the primary reason for the [TM55] not being on grade level?
[TM56]
SAFETY
1. / [TM57] Yes [TM58] No An In-Home Safety Plan is necessary to ensure safety of the child(ren) and control threats which would otherwise result in imminent risk of placement.
2. / Safety Services
The Identified Safety Threat; Diminished Protective Capacity; and the associated Safety Service / Action Type, Safety Service Provider and the specific explanation of the safety service / action and how it will control the threat identified are listed below:
Identified Safety Threat
[TM59]
Safety Service / Action Type
[TM60] / Safety Service Provider
[TM61]
Describe the availability, accessibility and suitability of the safety service provider involved.
[TM62]
Specifically explain the safety service / action and how it will control the threat identified.
[TM63]
Type of Diminished Protective Capacity: [TM64]
Parent / Caregiver Protective Capacity was assessed and enhancement is needed in the following area(s):[TM65]
Demonstrated Behavioral Change needed for safe case closure.
[TM66]
3. / Safety Decision
[TM67]In-home Safety Plan remains sufficient, feasible, and sustainable
[TM68]In-home Safety Plan revised
[TM69]Placement in out-of-home care is indicated
[TM70]Safe case closure
PLANNING AND SERVICES
Identify and describe the court ordered objectives, the actions taken and the services offered or provided by the agency in the previous six months and those to be provided in the next six months to achieve the goal(s) of the Case Plan, including services that were recommended or considered but were not available.
Describe the [TM71]’s general functioning.
[TM72]
Name of Child: [TM73]
Condition / Objective: [TM74]
Goal: [TM75]
Service category: [TM76]
Specifically explain service: [TM77]
Responsible person / provider: [TM78]
Frequency / Duration: [TM79]
Begin date: [TM80]End date: [TM81]
Describe progress: [TM82]
Status of service: [TM83]
For each parent / caregiver, describe how adult functioning (general functioning, daily life management, mental health functioning and substance use) impacts parenting practices (disciplinary approaches, nurturing, limit setting, protectiveness, provision of basic care, etc.). When a child is unsafe, determine how diminished parent / caregiver protective capacities impact impending danger threats (foreseeable danger) to safety.
[TM84]
Name of Parent / Caregiver: [TM85]
Condition / Objective: [TM86]
Goal: [TM87]
Service category: [TM88]
Specifically explain service: [TM89]
Responsible person / provider: [TM90]
Frequency / Duration: [TM91]
Begin date: [TM92]End date: [TM93]
Describe progress: [TM94]
Status of service: [TM95]
Describe the family’s general functioning, strengths and current stresses. Consider the family’s cultural context.
[TM96]
Family Condition / Objective: [TM97]
Goal: [TM98]
Service category: [TM99]
Specifically explain service: [TM100]
Responsible person / provider: [TM101]
Frequency / Duration: [TM102]
Begin date: [TM103]End date: [TM104]
Describe progress: [TM105]
Status of service: [TM106]
SIGNATURES
[TM107] / [TM108]
Name – Worker / Date Completed
SIGNATURE – Worker / Date Signed
[TM109] / [TM110]
Name – Supervisor / Date Completed
SIGNATURE – Supervisor / Date Signed
Case Plan
DCF-F-2828-E (N. 07/2013)Page 1 of 3
[TM1]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Legal Record page.
[TM2]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Case/Permanency Plan page.
[TM3]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Case/Permanency Plan page.
[TM4]This field is pre-filled.
This field is not editable on the template.
The data canbe corrected as follows: update Maintain Case page.
[TM5]This field is pre-filled.
This field is not editable on the template.
The data cannot be corrected.
[TM6]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Person Type for the child via the Person Management page to determine if the child is a child or a youth.
[TM7]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Basic tab of the child's/youth's Person Management page.
[TM8]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Person Type for the child via the Person Management page to determine if the child is a child or a youth.
[TM9]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Basic tab of the child's/youth's Person Management page.
[TM10]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Plan Date field in the Basic group box of theCase/Permanency Plan page.
[TM11]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the County field on the Maintain Case page.
[TM12]This field is pre-filled.
This field is not editable on the template.
The worker's name pre-fills from the Approval History page after final approval of the Case/Permanency Plan page.
The data cannot be corrected.
[TM13]This field is pre-filled.
This field is not editable on the template.
The supervisor's name pre-fills from the Approval History page after final approval of the Case/Permanency Plan page.
The data cannot be corrected.
[TM14]This field is pre-filled.
This field is not editable on the template.
The data cannot be corrected.
[TM15]This field is pre-filled.
This field is not editable on the template.
This field will pre-fill with the child's/youth's name.
The data can be corrected as follows: update the Basic tab of the child's/youth's Person Management page.
[TM16]This field is pre-filled.
This field is not editable on the template.
This field pre-fills Services if the ‘Prefill Templates’ checkbox is selected on the Maintain Service Type and Rate page for the associated Service Type.
The data can be corrected as follows: update on the Service tab of the Service page for a pending Service. For a closed Service, the data cannot be corrected.
[TM17]This field is pre-filled.
This field is not editable on the template.
This field pre-fills Services if the ‘Prefill Templates’ checkbox is selected on the Maintain Service Type and Rate page for the associated Service Type.
The data can be corrected as follows: update on the Service Ending page (via the Service tab of the Service page) for an open Service. For a closed Service, the data cannot be corrected.
[TM18]This field is pre-filled.
This field is not editable on the template.
This field pre-fills Services if the ‘Prefill Templates’ checkbox is selected on the Maintain Service Type and Rate page for the associated Service Type.
The data can be corrected as follows: update on the Service tab of the Service page for a pending Service. For a closed Service, the data cannot be corrected.
[TM19]This field is pre-filled.
This field is not editable on the template.
This field pre-fills Services if the ‘Prefill Templates’ checkbox is selected on the Maintain Service Type and Rate page for the associated Service Type.
The provider pre-fills from the Provider tab of the Service page for all placements recorded for the placement episode.
The data can be corrected as follows: update on the Provider tab of the Service page for a pending Service. For a closed Service, the data cannot be corrected.
[TM20]This field is pre-filled.
This field is not editable on the template.
This field will pre-fill with the child's/youth's name.
The data can be corrected as follows: update the Basic tab of the child's/youth's Person Management page.
[TM21]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Person Type for the child via the Person Management page to determine if the child is a child or a youth.
[TM22]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Medical /Mental Health tab of the child's Person Management page.
[TM23]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Person Type for the child via the Person Management page to determine if the child is a child or a youth.
[TM24]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Medical /Mental Health tab of the child's Person Management page.
[TM25]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Medical /Mental Health tab of the child's Person Management page.
[TM26]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Person Type for the child via the Person Management page to determine if the child is a child or a youth.
[TM27]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Medical /Mental Health tab of the child's Person Management page.
[TM28]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Medical /Mental Health tab of the child's Person Management page.
[TM29]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Medical /Mental Health tab of the child's Person Management page.
[TM30]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Person Type for the child via the Person Management page to determine if the child is a child or a youth.
[TM31]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Health Concern page, accessed from the Medical/Mental Health tab of the child's Person Management page.
[TM32]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Health Concern page, accessed from the Medical/Mental Health tab of the child's Person Management page.
[TM33]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Health Concern page, accessed from the Medical/Mental Health tab of the child's Person Management page.
[TM34]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Health Concern page, accessed from the Medical/Mental Health tab of the child's Person Management page.
[TM35]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Health Concern page, accessed from the Medical/Mental Health tab of the child's Person Management page.
[TM36]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Health Concern page, accessed from the Medical/Mental Health tab of the child's Person Management page.The Physician Address field pre-fills from the Medical Provider / Clinic page and is not editable on the template. The Physician Address fields can be updated on the Medical Provider / Clinic page.
[TM37]This field is pre-filled.
This field is not editable on the template.
The Physician, Dentist, or Mental Health Provider pre-fills from the child's Health Concern page.
The data can be corrected as follows: The Physician, Dentist, or Mental Health Provider can be updated on the Health Concern page by selecting the Primary? checkbox for the associated row. The Health Concern page is accessed via the Medical/Mental Health tab of the child's Person Management page.
[TM38]This field is pre-filled.
This field is not editable on the template.
The Physician, Dentist, or Mental Health Provider pre-fills from the child's Health Concern page.
The data can be corrected as follows: The Physician, Dentist, or Mental Health Provider can be updated on the Health Concern page by selecting the Primary? checkbox for the associated row.The Physician, Dentist, or Mental Health Provideraddress and phone numbers can be updated on the Medical Provider/Clinic page. The Date of Last Exam can be updated on the Health Concern page. The Health Concern page can be accessed via the Medical/Mental Health tab of the child's Person Management page.
[TM39]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Medical /Mental Health tab of the child's Person Management page.
[TM40]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Medical /Mental Health tab of the child's Person Management page.
[TM41]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Person Type for the child via the Person Management page to determine if the child is a child or a youth.
[TM42]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Medical /Mental Health tab of the child's Person Management page.
[TM43]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Well-Being tab of the Case/Permanency Plan page.
[TM44]This field is pre-filled.
This field is not editable on the template.
Either "A request for the child's immunization record was made to" with the Date Requested OR"Child's immunization record listed below" will pre-fill.
The data can be corrected as follows: update the Medical/Mental Health tab of the Person Management page.
[TM45]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Medical/Mental Health tab of the Person Management page.
[TM46]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Medical/Mental Health tab of the Person Management page.
[TM47]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Person Type for the child via the Person Management page to determine if the child is a child or a youth.
[TM48]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Education tab of the child's Person Management page.
[TM49]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: update the Education tab of the child's Person Management page. The child's school is identified with the Primary checkbox on the Maintain Education History page.
[TM50]This field is pre-filled.