Family & Community
Action Plan
Guidebook
What is the Family & Community Action Plan?
The Family & Community Action Plan is a tool to use in
the Wraparound Process. Its purpose is to design and
help successfully implement multi-agency, communitybased involvement with families. The Wraparound
Process requires full inclusion of the family and identifies
the services and supports needed by the child and family.
This process occurs in consultation with other members
of the Wraparound Team. The Family & Community
Action Plan is divided into several life domains including
behavioral health, substance use, medical, residential,
home & family, social/cultural/community,
educational/vocational, financial, legal and safety/risk
management. For each identified need there are specific
actions and resources that are listed. The plans must be
strengths-based and child and family driven. Data are
collected from the Family & Community Action Plan for
the purpose of determining outcomes, consumer
satisfaction and service system competency.
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Core Values for the System of Care
1. The system of care is child centered with the needs of the child and family dictating the types
and mix of services provided.
2. The system of care is community based, with the locus of services as well as the management
and decision-making responsibility resting at the community level.
Guiding Principles for the System of Care
1. Children who are emotionally disturbed will have access to a comprehensive array of services
that address the child’s physical, emotional, social and educational needs.
2. Children who are emotionally disturbed will receive individualized services in accordance
with the unique needs and potentials of each child and guided by an individualized service
plan.
3. Children who are emotionally disturbed will receive services within the least restrictive, most
normative environment that is clinically appropriate.
4. The families and surrogate families of children who are emotionally disturbed will be full
participants in all aspects of the planning and delivery of services.
5. Children who are emotionally disturbed will receive services that are integrated, with linkages
between child-serving agencies and programs and mechanisms for planning, developing and
coordinating services.
6. Children who are emotionally disturbed will be provided with case management or similar
mechanisms to ensure that multiple services are delivered in a coordinated and therapeutic
manner and that they can move through the system of services in accordance with their
changing needs.
7. Early identification and intervention of children who are emotionally disturbed will be
promoted by the system of care in order to enhance the likelihood of positive outcomes.
8. Children who are emotionally disturbed will be assured of smooth transitions to the adult
service system as they reach maturity.
9. The rights of children who are emotionally disturbed will be protected, and effective advocacy
efforts for children who are emotionally disturbed will be promoted.
10. Children who are emotionally disturbed will receive services that are sensitive and responsive
to cultural differences and special needs. Services shall be provided without regard to race,
religion, national origin, sex, physical disability or other characteristics.
Adapted from: A System of Care for Emotionally Disturbed Children & Youth, by Beth A.
Stroul & Robert M. Friedman, July 1986.
Glossary of Terms
At Risk for Serious Emotional Disturbance: See definition for serious emotional disturbance
below.
Basic Needs: Needs that everyone has in order to live including but not limited to,
transportation, food, shelter, clothing, heat, phone, gas, lights, sleep, respite, after school
programs, and recreation. Basic needs of the family need to be met before anything else is done
with the family.
Case Manager: An individual who organizes and coordinates services and supports for children
with mental health issues and their families.
Case Management: A service that helps people arrange appropriate family-driven services and
supports. Different agencies have different titles for these workers, e.g. service coordinator,
family outreach specialist, family support worker.
Community: A group of individuals living in the same area as the child and family; the place
where interventions for the wraparound process occur, the natural setting of the child/family. The
community must be invested in order for wraparound to be successful.
Community Based: Means that services and supports happen in the community where the
family lives, works, goes to school, and recreates. Services are provided in places that support
the needs of the family versus the service providers.
Cultural Competence: Help that is sensitive and responsive to cultural differences. Caregivers
need to be aware of the impact of their own culture and possess skills that help them provide
services that are appropriate in responding to people’s unique cultural differences, such as race
and ethnicity, national origin, religion, age, gender, sexual orientation, or physical disability.
Providers adapt their skills to fit a family’s values and customs.
Family: For the purpose of wraparound, family is ideally a person or group of people that
provides for the emotional, physical, and financial support of the child. Members of a family
may or may not be related.
Family Centered: Help designed for the unique needs of each individual and his or her family.
Children and families should not be expected to fit into services that don’t meet their needs.
Family Driven: Family centered services that reflect family expectations and preferences and
are ultimately approved by the family.
Family Preparation: Work that needs to be done prior to the initial Wraparound meeting
including identifying the strengths and needs of the family (see strengths chat).
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Flexible: Looking beyond just the available or traditional service array and not working from
preconceived notions. Never saying "no" without thinking of what the "yeses" could be.
Adapting to the evolving strengths and needs of a family in a responsive and timely manner.
Families function 24 hours a day, 7 days a week, 365 days a year and being flexible recognizes
this.
Home: The place where the family attempts to meet the basic needs of all, where the family
lives and should feel comfortable.
Individualized: Specifically tailored to meet unique needs of a child and family’s strengths,
values, norms, and preferences. It also means doing whatever it takes to succeed.
Natural Supports: Family, friends, neighborhood and community resources that a family can
draw on for support. These include supports that are already identified as a part of a family's
support system or can be developed into a support system. The family can access these resources
without using the system. These are resources available to all people, not just people who are in
the system. These are supports that the family can use that may or may not have costs associated
with them. Examples: NAMI, family, food bank, church, community, friends. Plans and
interventions should build upon natural supports and over time decrease dependence on the
professional service system.
Need: Something required or desirable to achieve optimal functioning in an individual and his
or her family. A need is a reframing of a “problem”; needs are described and identified from the
child/family’s perspective rather than from the professional’s perspective; all needs are identified
in the wraparound process regardless of whether or not services are available.
Non-Compliance: Labeling a family as non-compliant is counterproductive and should not be
used. The term is judgmental as it justifies failure at the expense of the family. Services shall not
be denied because a family has been labeled as non-compliant.
Out of Home Placement: When a child/adolescent is not living with their family. Out of home
placements can include therapeutic foster care, living with other relatives, or residential
placement.
Outcomes: The effects of services and supports provided to a family. The family determines
whether the services implemented in the plan are meeting their needs and the team will readjust
the plan accordingly.
Plan: A plan is a document that is family-driven, strengths-based, culturally competent and has
measurable actions designed to address the needs identified by the child and family. The plan is
individualized and flexible. A plan is revised as often as necessary to meet the changing needs of
the child and family. A plan is written in the language of the child and family. Families must
feel included in this process, not blamed or betrayed. A plan should be consistent across agencies
that serve the child and the family. It is the case manager’s responsibility to see that this occurs.
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A plan designates responsibility to those who have specific actions to take. Plans will include all
family members and should include crisis planning.
Serious Emotional Disturbance: A term used to describe children and adolescents with
emotional or behavioral disorders under DSM IV who also have difficulty functioning within
their family, school, or community. For the purposes of this wraparound process these children
should have multi-agency needs involving two or more agencies.
At Risk for Serious Emotional Disturbance: A term used to describe children and adolescents
with emotional or behavioral disorders under DSM IV who may, without appropriate supports,
develop a more intense level of need.
Strengths: Family identified knowledge, skills, and resources that are used to orient the
development of plans. Services and supports should be built on the child and family’s strengths.
Strengths Chat: A necessary step in the wraparound process is performing an informal
strengths assessment with the child and family (and sometimes with the extended family network
and neighborhood) as part of preparing the family for the actual wraparound planning session. A
child and family’s strengths drive the planning process.
Team: A group consisting of the child, family, family identified friends and supports, service
providers, and other natural community supports as appropriate to the family’s needs. Ideally,
team membership should consist of at least 50% family, friends, and natural supports.
Unconditional Care: Doing whatever it takes to support the family and meet the family’s needs.
Unconditional care means not blaming the child or family. It also means being committed to
work with the family in creative and flexible ways for as long as is needed until the services and
supports work. The bottom line is that unconditional care means a “No Eject, No Reject
Policy.”
Wraparound Process: The process of working with families to develop wraparound services.
This process includes strengths chat with families and other family preparation, efficient meeting
facilitation, maintaining a feeling of safety for participants, and reflects family centered values
and attitudes.
Wraparound Services: “Interventions that are developed and/or approved by [a
multidisciplinary] services team [which includes the family and their supports], are community
based and unconditional, are centered on the strengths of the child and family, and include the
delivery of coordinated, highly individualized services in three or more life domain areas of a
child and family.” (The International Initiative on the Development, Training, and Evaluation of
WrapAround Services 1992)
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COMPLETING THE FAMILY & COMMUNITY ACTION PLAN FORM
(STEP BY STEP INSTRUCTIONS AND DEFINITIONS)
Family Preparation: Prior to having an actual wraparound team meeting, a support person the
family trusts should meet with the family to identify the appropriate family members, friends,
supports, and providers who will be members of that family’s wraparound team. Providers
include people working directly with the child and family. The strengths chat is a necessary part
of family preparation. Family preparation may take more than one visit especially if the support
person is new to the family.
Natural Resources: The goal in providing wraparound services to families is to use as many
natural resources and community supports as possible. The goal is to increase the use of natural
supports and the family’s own resources so that more of the family’s support, over time, comes
from natural supports rather than “professionals.”
Wraparound Meeting: After the family preparation, a wraparound meeting should be
scheduled at a time and place that takes into account the family’s work schedule and
transportation needs. The expectation is that all team members will play an active role in some
aspect of the plan. Wraparound meetings shall be held as frequently as the team deems
necessary. Meetings may occur at set intervals but there should always be a plan to call a
meeting sooner if necessary.
Cover Sheet: Purpose is to identify the members of the team and to have an efficient way for
all team members to reach one another. The signature lines should be completed at the end of the
meeting to signify agreement to the plan.
Column 1: The Domains There are 10 life domains identified below that are a part of the
Family & Community Action Plan. The family is engaged with their team in a conversation
that is designed to find out what has been successful for this family and what the family
needs help with now. These questions are often helpful in engaging families in this process:
What do you need? What do you think would be helpful? What have you tried? What has
worked? What has not worked? Who has worked well with you and what was it that made
you feel comfortable with them?
In keeping with the philosophy of unconditional care, only concerns that the family identifies
are to be addressed, for example substance use concerns are only addressed in the Family &
Community Action Plan once the family has identified them as a priority area. It is not
necessary or even desirable to create an action plan for every need identified; rather the team
should focus on the most critical needs as prioritized by the family.
a. Home & Family – Identifying strengths, needs and actions regarding the needs of child
and family in their home environment.
b. Safety & Risk Management – Identifying strengths, needs and actions regarding safety
in the home, school and community. This is a priority area for everyone and sensitive
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issues may arise. Mandated state reporting laws must be followed but this should be
accomplished in a way that respects the child and family.
c. Housing – Identifying strengths, needs and actions regarding where the child or family
lives; pertains to the physical environment that the family lives in.
d. Social, Community and Cultural – Identifying strengths, needs and actions regarding a
child and family’s social & community relationships including associations, recreation,
and spirituality that reflects a family’s values, belief system and culture.
e. Educational/Vocational – Identifying strengths, needs and actions regarding a child or
family member’s education or preparation for working.
f. Financial – Identifying strengths, needs and actions regarding a child or family’s
money/fiscal and material needs including income, benefits, insurance, purchasing of
services, and economic resources for basic needs.
g. Legal – Identifying strengths, needs and actions regarding a child or family’s
involvement with the courts, law enforcement, and legal actions in general. This could
include any type of court involvement including eviction, divorce, civil cases, criminal
cases, and child protections, delinquency, or children in need of services (CHINS).
h. Behavioral Health – Identifying strengths, needs and actions regarding the psychiatric,
psychological, and emotional needs of a child and/or family.
i. Substance Use – Identifying strengths, needs and actions regarding a child or family’s
difficulties with drugs (legal or illegal), alcohol and/or other addictions that impair
functioning.
j. Medical & Dental – Identifying strengths, needs and actions regarding the physical
health of the child and/or family members.
Column 2: Family Strengths and Supports During the initial discussions with a family,
strengths and supports must be identified for each of the ten domains. Sometimes these are
hard for families to identify or express, so the person preparing the family for the wraparound
experience will need to be mindful of ways to draw out the family.
Examples include: Extended family and friends, connection to a faith community, a friend
willing to provide respite, family cares for own financial and housing needs, hobbies and
extra curricular activities of members of the family, long term relationship with a support
person (professional or non-professional, formal or informal), willingness to seek help,
transportation, parental support, symptom management, medical care, dental care, crisis plan,
day care, Special Education (SPED) in place, early intervention, job/job training, advocacy,
case management, legal advice, substance use treatment, evaluation/assessment, mental
health treatment/specific treatment, leisure time and recreation, parenting skills, safety,
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therapeutic foster care/home, medication, therapy, educated regarding illness, family
closeness, doing things together, mutual respect, family has fun together, and how the family
resolves problems.
Column 3: Family Identified Needs All needs are individualized and identified by the family.
If the family does not identify a need, then it will NOT appear on the Family & Community
Action Plan. The goal for the team is to reach consensus with the family in the identification
of needs and interventions. The only exception to this would be supports and services
ordered by a court. These may be non-negotiable but still must be handled in a respectful
manner.
Strengths and needs are two sides of a coin: Needs may fall into similar categories as the
strengths listed above.
Column 4: Actions Refers to the plans developed to address the family’s needs. Actions are
solution focused and are designed to address specific needs. Actions will be measurable,
meaning the team will be able to judge whether actions are successful. Actions should be
focused on supporting and building upon strengths. Do not overwhelm the team by listing
all actions—prioritize actions that need immediate attention. Actions can be added or
changed each time the team meets.
Column 5: Person Responsible The team member who has agreed to be responsible for
carrying out the actions identified in the previous column.
Column 6: Resources/Providers Use this column to identify potential natural resources and/or
provider agencies that can assist with the action.
Column 7: Start Date The date the action identified in the plan is to begin.
Column 8: Completion Date The date the action identified in the plan is to be completed.
FOLLOW-UP
These columns should be completed prior to the next wraparound meeting or could be reviewed
at the beginning of the meeting.
Column 9: Needs Met This is the family’s rating of how well their needs have been met in each
domain using the following scale:
5 = Absolutely
4 = Mostly
3 = Somewhat
2 = Not Much
1 = Not at All
Columns 10 & 11: Comments About Outcomes This is an opportunity for family and all other
team members to reflect on the plan and to honestly and safely discuss what is working and
what isn’t working. There should be NO SHAME and NO BLAME involved.
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