Children's Residential Center
CRC INDIVIDUALIZED SERVICE PLAN/CASE PLAN REVIEW
Client Name:
Date:
(rev 20150911)
Client No.
(First, MI, Last)
Present at Session ☐Client Present Client ☐No-show/Canceled [If others present, list name(s) and relationship(s) to client in
the line below.]
The following outcome measures are attached:
Diagnosis:
Revision in the result of a Mental Health Assessment Updated: Click here to enter text.
☐ Behavioral Intervention Plan
☐ Pediatric Symptom Checklist
☐ PTSD Questionnaire
Axis I:
Axis II:
Axis III:
Axis IV:
1. Client's and/or guardian's account of progress toward alleviating safety threats, risks and/or circumstances
to child being placed in a least restrictive environment:
Client:
Guardian:
2. Conclusion regarding appropriateness of residential services provided to the child and/or his/her parent,
guardian, or custodian:
3. An assessment of the engagement of the client in the ISP/Case Plan and the extent of compliance by all case
plan participants:
4. Evaluation of whether services provided to the child, his/her parent(s), guardian, or custodian will help child
return to safe environment(if applicable):
☐Client obtained the following skills over review period:
☐Client’s family and community systems obtained the following skills:
☐The following supports were found beneficial to the client and his/her systems over the review period:
☐The following supports will be beneficial for the client and his/her systems over the next review period:
☐The following referrals were made over the review period:
☐With positive impact and/or follow thru with negative impact and/or follow thru
5. Description of how child's current placement is appropriate for child's specific safety needs and meets
child's basic and special needs (summary of residential services):
COUNSELING SERVICES
Diagnosis:
Progress: Regression
Goal:
As evidenced by the following:
Diagnosis:
Progress: Moderate
Goal:
As evidenced by the following:
Diagnosis:
Progress: Minimal
Goal:
As evidenced by the following:
Diagnosis:
Progress: Significant
Children's Residential Center
Goal:
As evidenced by the following:
EDUCATIONAL SERVICES –Progress: Minimal
As evidenced by the following:
VOCATIONAL SERVICES-Progress: Moderate
As evidenced by the following:
MEDICAL SERVICES AND MEDICAL DIAGNOSIS- Progress: Moderate
As evidenced by the following:
Current client medication(s):
PSYCHIATRIC SERVICES- Progress: Moderate
Per Dr Thomas Reynolds MD
Diagnoses offered by contract psychiatric service provider. Diagnostic criteria will continue to be reviewed to determine
accuracy.
SPECIALIZED SERVICES
Cottage Level/Target Skill Development-Progress: Minimal
As evidenced by the following:
Current Target Skills:
Horse Therapy-Progress: Significant
As evidenced by the following:
VISITATION/COMMUNICATION-Progress:
As evidenced by the following:
RECREATION SERVICES-Progress:
As evidenced by the following:
RELIGIOUS/SPIRITUAL SERVICES-Progress:
As evidenced by the following:
24-HOUR SUPERVISION-Progress:
As evidenced by the following:
6. Summary of on-going efforts to identify an appropriate placement:
7. Discharge plan and estimated date child may be discharged/returned and safely maintained at home, placed
with a relative, identified foster home, or other identified placement:
☐N/A (Unidentified)
8. Level of Care:
☐Client needs continued placement in order to maintain current level of functioning
☐Transfer/Discharge plans needs to be developed with client, guardian, and treatment team
☐Placement review request-reason:
9. Revision to ISP/Case Plan:
Children's Residential Center
☐No Change to ISP/Case plan
Signature Page:
The risks and benefits of the above treatments, along with alternative treatments, have been explained to the belownamed client and/or guardian, and both client and guardian agree to the continuation of the proposed plan. Both client
and guardian understand that that they have the right, at any time, to refuse treatment.
PROVIDER(S): The below named providers have participated in the review of the clients ISP.
NOTE: CHANGES ON THE PLAN MUST BE DATED AND INITIALED.
Was client provided copy of Individualized Service/Recovery Plan Review?
☐Yes, Client received copy
☐No, Client did not want copy ☐Client Initials to confirm _______
The frequency of progress reports that will be provided to the individual and/or custodial agency which placed
the child:
☐Every 30 days
☐Every 45 days
_____________________________________________
_____________________________________________
Client
Cottage Representative
Date
Date
_____________________________________________
_____________________________________________
Therapist/Licensed Professional Approving ISP
Residential Admin. Asst.
Date
Date
_____________________________________________
_____________________________________________
Clinical Supervisor
Residential Director
Date
Date
_____________________________________________
_____________________________________________
Physician
Other
Date
Date
______________________________________________
_____________________________________________
Guardian
Other
Date
______________________________________________
Date
_____________________________________________