Assessment booklet

Case Management Plan

Service User

CONSENT CHECKLIST

Before developing this plan, ensure consent to share information has been obtained.

To ensure that the Service User is able to make an informed decision about consent to the disclosure of their information, the service provider has discussed the following and secured agreement from the Service User for:

Name:

Date of birth:

Sex:

1. The proposed referral to other services/agencies

2. Use of the Service User’s information in referral under the requirements of privacy legislation

Service User’s signature: Verbal agreement:

Name

Role or area of support

Contact phone number/s

Other relevant contact details (e.g., agency, email)

Participant in planning process (yes/no)

Copy of plan provided (yes/no)

Opportunities

(list in order of priority)

Agreed goal (measurable)

Action/s to be taken , by whom & expected outcome/s

Target date

1

1.1

1.2

2

2.1

2.2

3

3.1

3.2

4

4.1

4.2

5

5.1

5.2

Plan developed (date):

Target review (date):

Service User understands and agrees to this plan:

YES ☐ NO ☐

This plan is prepared by:

Name:

Date:

Signature:

We agree to carry out the responsibilities outlined in this Case Management plan to the best of our ability:

Please sign and date

Signature of Client:

Date:

Signature of Case Manager:

Date:

Signature of Service Provider:

Date:

Signature of Service Provider:

Date:

Signature of Service Provider:

Date:

Version: 1.0

Page 4 of 4

Created: April 2021

Last Reviewed: April 2021