SMART

hn330_u7_sample_individualized_service_plan.docx

Home >Business & Finance homework help >Economics homework help >SMART

HN330: Individualized Service Plan Form Page | 5

Course: HN330

Individualized Service Plan Form

Client Name: Sarah Freeman

Date of Birth: 11/22/1976

Next of Kin: Claire Freeman, Mother

Date: 6/5/2015

Review Date: 9/5/2015 (3 months)

Initial Plan: X

Updated Plan:

Developed with: Sarah Freeman and her Case Manager, Jennifer Hutras

Type of Case Management:

Administrative CM

Resource Coordination CM: X

Intensive CM

Targeted or Blended CM

Case Manager: Jennifer Hutras

DSM 5 Diagnostic Impression/Provisional Diagnosis: Depression

Statement of what I envision my life will be like when I achieve my goals:

“I would like to feel confident in my ability to care for my 5 children. I would like to reconnect with my family, friends and community. I would like to start working again so that I can contribute to paying off my student loan. I would like to explore alternatives to alcohol in coping with my depression. Finally, I would like some additional assistance in caring for my 8 year old son who was diagnosed with Autism.”

DOMAIN

STRENGTH/NEED

(select one)

GOAL(S)

ACTION STEPS

TARGET

DATE(S)

INCOME/FINANCIAL SITUATION

Strength

Sarah’s husband will continue to work full time to support their family.

HOUSING LIVING ARRANGEMENT

Strength

Sarah’s family lives in a home that meets their needs.

VOCATIONAL

Need

Sarah will find a part-time teaching assistant position by September 2015.

Sarah will review local job listings and apply for 3 teaching assistant positions.

Job applications will be submitted by, July 15, 2015.

EDUCATIONAL

Strength

Sarah has a degree that will allow her to find the job that she wants.

TRANSPORTATION

Strength

Sarah’s family has reliable transportation.

MEDICAL

Strength

Sarah’s family has medical/dental care and insurance.

ACTIVITIES OF DAILY LIVING

Strength

LEGAL

Strength

No legal needs at this time.

RECREATION &

LEISURE TIME

Need

Sarah will resume attending the women’s writing group that she used to belong to.

Sarah will call the group facilitator to see when the group is meeting over the next few months.

Sarah will attend 1 group before September 2015.

Initial phone call to be made week of June 22, 2015.

Ongoing.

Will review on 9/5/2015 with Case Manager.

MENTAL HEALTH

Need

Sarah will take steps to manage her depression by August 2015.

Sarah met with Susan Davies on 6/1/2015 for Psychiatric Evaluation.

Sarah will continue to meet with her 1 time per week.

Ongoing. Will review on 9/5/2015 with Case Manager.

SUBSTANCE ABUSE

Need

Sarah will take steps to curb her alcohol intake.

Sarah will attend her first AA meeting on 6/8/2015 and will continue to attend one time per week.

Ongoing. Will review on 9/5/2015 with case manager.

FAMILY RELATIONSHIPS

Need

Sarah will use the Family Place to participate in support groups, parent education and playgroups.

Sarah will call the Family Place to request the Summer 2015 calendar.

Sarah will attend 1 activity per week starting the week of June 8th.

Ongoing. Will review on 9/5/2015 with Case Manager.

SPIRITUAL

Need

Sarah will use her Church community to reconnect spiritually to family and friends.

Sarah will attend church 2 times per month, starting the week of June 8th.

Ongoing. Will review on 9/5/2015 with Case Manager.

SOCIAL SUPPORTS

Need

Will re-evaluate at 3-month review. Social Supports being addressed in other areas, at this time.

OTHER

Need

Sarah will find in-home support for her 8-year-old son.

Sarah will call her son’s school and request a referral for in-home care.

Initial phone call to be made week of June 8, 2015.

Client Signature: Sarah Freeman

Date: 6/5/2015

Legal Guardian’s Signature (if one is assigned or if client is under 18):

Date:

Case Manager Signature: Jennifer Hutras

Date: 6/5/2015

Supervisor Signature: Janelle Evans, LCSW (Licensed Clinical Social Worker

Date: 6/5/2015

Instructor Feedback:

DOMAIN	STRENGTH/NEED (select one)	GOAL(S)	ACTION STEPS	TARGET DATE(S)
INCOME/FINANCIAL SITUATION	Strength	Sarah’s husband will continue to work full time to support their family.
HOUSING LIVING ARRANGEMENT	Strength	Sarah’s family lives in a home that meets their needs.
VOCATIONAL	Need	Sarah will find a part-time teaching assistant position by September 2015.	Sarah will review local job listings and apply for 3 teaching assistant positions.	Job applications will be submitted by, July 15, 2015.
EDUCATIONAL	Strength	Sarah has a degree that will allow her to find the job that she wants.
TRANSPORTATION	Strength	Sarah’s family has reliable transportation.
MEDICAL	Strength	Sarah’s family has medical/dental care and insurance.
ACTIVITIES OF DAILY LIVING	Strength
LEGAL	Strength	No legal needs at this time.
RECREATION & LEISURE TIME	Need	Sarah will resume attending the women’s writing group that she used to belong to.	Sarah will call the group facilitator to see when the group is meeting over the next few months. Sarah will attend 1 group before September 2015.	Initial phone call to be made week of June 22, 2015. Ongoing. Will review on 9/5/2015 with Case Manager.
MENTAL HEALTH	Need	Sarah will take steps to manage her depression by August 2015.	Sarah met with Susan Davies on 6/1/2015 for Psychiatric Evaluation. Sarah will continue to meet with her 1 time per week.	Ongoing. Will review on 9/5/2015 with Case Manager.
SUBSTANCE ABUSE	Need	Sarah will take steps to curb her alcohol intake.	Sarah will attend her first AA meeting on 6/8/2015 and will continue to attend one time per week.	Ongoing. Will review on 9/5/2015 with case manager.
FAMILY RELATIONSHIPS	Need	Sarah will use the Family Place to participate in support groups, parent education and playgroups.	Sarah will call the Family Place to request the Summer 2015 calendar. Sarah will attend 1 activity per week starting the week of June 8th.	Ongoing. Will review on 9/5/2015 with Case Manager.
SPIRITUAL	Need	Sarah will use her Church community to reconnect spiritually to family and friends.	Sarah will attend church 2 times per month, starting the week of June 8th.	Ongoing. Will review on 9/5/2015 with Case Manager.
SOCIAL SUPPORTS	Need	Will re-evaluate at 3-month review. Social Supports being addressed in other areas, at this time.
OTHER	Need	Sarah will find in-home support for her 8-year-old son.	Sarah will call her son’s school and request a referral for in-home care.	Initial phone call to be made week of June 8, 2015.