Discharge Summary and 1 page- Documents attached to help complete.
HN330: Individualized Service Plan Form
Page | 5
Course: HN330
Individualized Service Plan Form
Client Name: Bo
Date of Birth: 1/7/2004
Next of Kin: Tammy (Mother)
Date: 1/7/2017
Review Date: 7/9/2017
Initial Plan: X
Updated Plan:
Developed with: Tammy
Type of Case Management:
Administrative CM
Resource Coordination CM
Intensive CM
Targeted or Blended CM
Case Manager: Amanda Gonzalez
DSM 5 Diagnostic Impression/Provisional Diagnosis: **
Statement of what I envision my life will be like when I achieve my goals:
“I would like to have a beautiful home which I am confident in. I also want to go to high school and college so that I can achieve my dreams and help out my mom. I would like to have friends who are supportive, helpful and who accept who I am. I would also like to avoid drugs so that I can focus on my schooling.
| DOMAIN | STRENGTH/NEED (select one) | GOAL(S) | ACTION STEPS | TARGET DATE(S) |
| INCOME/FINANCIAL SITUATION | Strength | Bo’s mother has a job. She’ll continue working to support her family. | ||
| HOUSING LIVING ARRANGEMENT | Strength | Bo’s family has a house which sustains their needs. | ||
| VOCATIONAL | Strength | Bo is 13, a minor and still going to school. | ||
| EDUCATIONAL | Need | Bo needs close follow-up on his school attendance. He also needs personalized help with his performance in school. | Tammy will visit school to learn from Bo’s teacher about his performance. | Will be Done immediately after Summer break. |
| TRANSPORTATION | Need | Bo’s family does not have reliable means of transformation | Tammy intends to fix up her car. | |
| MEDICAL | Need | Family does not have dental/medical care or insurance. | Enroll for healthcare insurance. | Immediately |
| ACTIVITIES OF DAILY LIVING | Need | Bo (and his brother, Matt) needs help with his self-esteem. | Enroll in self-esteem workshops for children. | |
| LEGAL | Strength | Bo has no legal needs. | ||
| RECREATION & LEISURE TIME | Need | Bo needs productive leisure activities. His current situation keeps him vulnerable to drug abuse. | ||
| MENTAL HEALTH | Need | Tammy feels that Bo has difficulty in learning. Bo needs mental health evaluation | Bo will have an appointment with a doctor accompanied by his parent. | Initial meeting will be on 30/7/2017 |
| SUBSTANCE ABUSE | Need | Bo needs support since most of the people in his life | Bo will have an appointment with a doctor, accompanied by his parent. | Initial meeting will be on 3/8/2017 |
| FAMILY RELATIONSHIPS | Strength | Bo’s family is united. | ||
| SPIRITUAL | Need | Bo needs to part of a church community where he can get spiritual help. | Tammy will become a member of a close church community.\ | |
| SOCIAL SUPPORTS | Need | Will be re-evaluated in a month’s time. | ||
| OTHER | Need | Bo needs to live in a clean environment | They will tidy up they home surrounding to make it clean and neat. | Immediately |
Client Signature: Bo
Date: 7/3/2017
Legal Guardian’s Signature (if one is assigned or if client is under 18): Tammy (Mother)
Date: 7/3/2017
Case Manager Signature: Ary North
Date: 7/3/2017
Supervisor Signature: Eve Evans, LCSW (Licensed Clinical Social Worker
Date: 7/3/2017
Instructor Feedback:
