Developed within 7 working YES NO days of Needs Assessment? The Case/Service Plan includes the following: Individualized and prioritized YES NO need(s) and goal(s) identified by the Needs Assessment? Service type, frequency, YES NO location? Person(s) responsible? YES NO Target date(s) for completion? YES NO YES NO Actual completion date(s)? YES NO Signature of Signature of Parent/guardian? YES NO YES NO Signature of counselor? YES NO Signature of supervisor? Date the plan was initiated? YES NO Problem Identified Counselor Response Outcome Reviewed for progress/revised by counselor and parent (if YES NO available) every 30 days for the first three months and every 6 months after? 2.04 Case Management and service Delivery Problem Identified Counselor Response Outcome Counselor/Case Manager is YES NO assigned? The Counselor/Case Manger completes the following: Evidence of action is documented Establishes referral needs and YES/NO coordinates referrals to services based upon the N/A assessment of the
Developed within 7 working days of Needs Assessment? YES NO The Case/Service Plan includes the following: Individualized and prioritized need(s) and goal(s) identified by the Needs Assessment? YES NO Service type, frequency, location? YES NO Person(s) responsible? YES NO Target date(s) for completion? YES NO Actual completion date(s)? YES NO Signature of YES NO Signature of Parent/guardian? YES NO Signature of counselor? YES NO Signature of supervisor? YES NO Date the plan was initiated? YES NO Problem Identified Counselor Response Outcome Reviewed for progress/revised by counselor and parent (if available) every 30 days for the first three months and every 6 months after? YES NO 2.04 Case Management and service Delivery Problem Identified Counselor Response Outcome Counselor/Case Manager is assigned? YES NO The Counselor/Case Manger completes the following: Evidence of action is documented Establishes referral needs and coordinates referrals to services based upon the assessment of the YES/NO N/A
peer_rev_2017.docx