Attachment 1 Client Name: Meeting Date: Serial #: Projected Placement Date: Services Goals/Objectives Prior To Placement Frequency/Comment Person(s) Responsible Support Current SC /CM: Sending SC/CM is responsible for Coordination (SC) Current SC/CM Supervisor: securing information. / Case Receiving SC/CM: Management Receiving SC/CM Supervisor: (CM) Annual Plan Date: Sending SC/CM is Living Current Living Arrangement: Discuss the need for a fire responsible for drill to be completed during Arrangement New Living Arrangement- Name: securing information. the first overnight visit to the Address: new home. Telephone # : Ambulation Concerns? In-service training needed? Identify the number of transition visits needed: Shadow visits: ______ Day visits: _______ Overnight visits: ______ Identify issues related to placement: ☐ ☐ Sending Identification Discuss whether original Birth Certificate: Yes No SC/CM/Natural documents are needed or if Documentation ☐ ☐ Social Security Card: Yes No Support is responsible copies will be accepted. ☐ ☐ for securing State ID: Yes No information. Other ID: ☐ ☐ Health Insurance Cards: Yes No Sending SC/CM is Employment/ Current Job/Day Program: Work / Day Program hours of responsible for operation: Education/ Name/site of new Job/Day Program: securing supports and Habilitation Referrals sent, if site is not identified above: services. Transportation arrangements: Contact Person: Telephone #: Date of visit to site: Sending SC/CM is Family/ Family Contacts: Frequency of contact responsible for identified by client: Community Address: securing information. Contacts Telephone Number: Religious/Civic Affiliations: DCF/APS Contacts: Fiscal CCW Eligible: Yes No Discuss Contribution to Care Sending SC/CM is responsible for with individual and family: Supports Program Eligible: Yes No securing information. SSA Benefits: Yes No Cash on Hand should be SSI Benefits: Yes No brought on the day of move. Other Benefits: Discuss amount: Payee Name:
Attachment 1 Client Name: Meeting Date: Serial #: Projected Placement Date: Services Goals/Objectives Prior To Placement Frequency/Comment Person(s) Responsible Support Coordination (SC) / Case Management (CM) Current SC /CM: Current SC/CM Supervisor: Receiving SC/CM: Receiving SC/CM Supervisor: Annual Plan Date: Sending SC/CM is responsible for securing information. Living Arrangement Current Living Arrangement: New Living Arrangement- Name: Address: Telephone # : Ambulation Concerns? In-service training needed? Identify the number of transition visits needed: Shadow visits: ______ Day visits: _______ Overnight visits: ______ Identify issues related to placement: Discuss the need for a fire drill to be completed during the first overnight visit to the new home. Sending SC/CM is responsible for securing information. Identification Documentation Birth Certificate: Yes ☐ No ☐ Social Security Card: Yes ☐ No ☐ State ID: Yes ☐ No ☐ Other ID: Health Insurance Cards: Yes ☐ No ☐ Discuss whether original documents are needed or if copies will be accepted. Sending SC/CM/Natural Support is responsible for securing information. Employment/ Education/ Habilitation Current Job/Day Program: Name/site of new Job/Day Program: Referrals sent, if site is not identified above: Transportation arrangements: Contact Person: Telephone #: Date of visit to site: Work / Day Program hours of operation: Sending SC/CM is responsible for securing supports and services. Family/ Community Contacts Family Contacts: Address: Telephone Number: Religious/Civic Affiliations: DCF/APS Contacts: Frequency of contact identified by client: Sending SC/CM is responsible for securing information. Fiscal CCW Eligible: Yes No Supports Program Eligible: Yes No SSA Benefits: Yes No SSI Benefits: Yes No Other Benefits: Payee Name: Discuss Contribution to Care with individual and family: Cash on Hand should be brought on the day of move. Discuss amount: Sending SC/CM is responsible for securing information.
preplacement-transition-plan.docx