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9201 WATERTOWN PLANK RD MILWAUKEE WI PHONE: PLAN OF CARE 6PM

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ExpirationDate: WRAPAROUND WLWAUKEE 9201 WATERTOWN PLANK RD MILWAUKEE WI PHONE: PLAN OF CARE 1234 Any Strreet.WI Aggie Hale -Fostelr Parent 4753 S. 22nd Place Milwaukee, WI 53225
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ExpirationDate: WRAPAROUND WLWAUKEE 9201 WATERTOWN PLANK RD MILWAUKEE WI PHONE: PLAN OF CARE 1234 Any Strreet.WI Aggie Hale -Fostelr Parent 4753 S. 22nd Place Milwaukee, WI nd Family Member(i.e, mom, etc.) -Mentor Street Address City, State Zip Name: Community, Supervisor: QA SafeNow, Phone: Agency: Natural Supports Next POC Date: Location: 4/1/05 family home Next POC Time: 6PM /'{qm~ Mary Client Fathers Name Alyson Ambroso Jam(~sx Client Barbara Higgins James Seeb Aggie Hale Bill Smith Re/ationsh Mother Father Care Coordinator GrandParent Education Staff/ W2 worker Crisis Provider Type of:i~pq!t Neutral Neutral Neutral Informal Informal Formal Formal Formal Order Type: CHIPS 2/3/2005 Adj.Date Court Order Number: 0 I N I I P.O./Bureau Worker: Mark Taylor Permanency Judge: Plan: Relative Placement ~en~~~~~ ~~';;~~,... Schoo Name: Marshall High School Grade: 9th Contact Person: Mary Beth Jones Contact Phone: ~. Special Education: ED LD Page 1 of9 Date Printed: 2/7/2005 Youth Name: Client, Sample POC Date: 1/27/2005 POC Status: Pending Program A Date of Birth: 1/1/1991 EnroD Date: 4/3/04 POC Number: 6 ~ Family Vision: Known Allergies: bee stings xyz 1:.YJ! Used For inhaler asthma aspirin headaches ritalin hyper On Medication? ~ FreQuency ~cribed By ~ 5mg ~ dentist ~ Dr. Toothache ~ When Last Seen Spring, 2003 ~ Affiliated: Yes Active: Yes Faith Affiliation: Faith Contact: Baptist Pastor Martha Roberts Normal Development2Ll History? Comments: Yes Youth is Sexually Active? No Prior psychiatric hospitalization? No Comments: Uses cigarettes? Unknown Uses drugs? Prior History Uses alcohol? Prior History Comments: Josh has used Marijuana in the past An AODA group is being looked into for youth. ~ I I I II DCSCriPtlOD Parent-Child: Relational Problem Autistic Disorder Sexual Disorder NOS Paranoid Perrsonality Disorder m IV V Diagnoses By: Diagnoses Date: asthma divorce of parents 45 Month September 2004 October 2004 November 2004 December 2004 January 2005 Possible 20 2~ Attended/Excused Page 2 of9 Date Printed: 2/7/2005 Youth Name: Date of Birth: Client, Sample 1/1/1991 l'oc Date: 1/27/2005 roc Status: Pending Program A Family Vision: Percent of School Bays Attended 100% 100% 0.8 D.D OQ ~.Q1 No School Statistics By Plan of Care Date Exist Page 3 of9 Date Printed: mnoo5 Page 4 of9 Date Printed: 2/7/2005, .Family Background 0 Describe family composition 0 Ask the famil)r to discuss what led them to this point as well as the reason for referral 0 Discuss the fajrnily's values, beliefs, traditions, daily routines 0 Describe any mental health history or concerns and other significant factors (i.e., incarcerations, abuse history, etc.) for family members 0 Discuss any out-of-home placements for the enrolled youth or other family members..behavioral History/Concerns 0 Describe the c]l1ild's past and present behavioral concerns 0 Discuss intervc~ntions tried in the past -what worked, what didn't 0 Discuss any school-related issues 0 Discuss any le:gal involvement, charges and offense history (including gang involvement or runaway history) 0 Discuss the chilld's sexual history 0 Describe any significant peer relationships.permanency PlJiDning 0 Discuss the pel:manency plan for this youth, and any barriers or concerns in this area. Family Narrative:s for all subsequent POCs should include:.an update on tile progress/concerns/changes in all of the domain areas. In addition, it should: 0 Discuss successesince the last Plan of Care. 0 Discuss any plllcement changes 0 Discuss any ~ljor losses since the last Plan of Care. 0 DiscUss any ~ljor changes to team composition and/or service providers 0 Provide an update on legal status (new charges, hearings held, etc.) 0 Provide an update on educational goals/school placement..permanency Planning 0 Discuss the tealn' s progress on working toward permanency for the youth. Page 5 of9 Date Printed: 2n/2005 Youth Name: Clierlt, Sample POC Date: 1/27/2005 POC Status: Pending Program A Date of Birth: 1/1/11991 Enron Date: 4/3/04 POC Number: 6 Family Vision: To reunify the children with their mother and to maintain stability. Crisis Plan Date: 1/10/2005 What is the Child and Family Team's Definition of a Crisis? Team definition of a crisis is Interests and Strengths of the Client Relevant to Crisis Situation Interests and strengths are.... Risky Situations or O.ther Factors Relevant to Crisis Prevention and Safety Risk factors are Family/Community S:upports Family supports... Community supports. Resources to be Used in Crisis Situations Crisis resources are... What Helps the CareJ~iver What helps the caregiver is Specific Strategies Based on Strengths to Resolve Crises Effective techniques are.... Relevant Medical Information new info Page 6 of9 Date Printed: 2/7/2005 )' outh Name: (:1ient, Sample roc Date: 1/27/2005 roc Status: Pending Program A Date of Birth: ]:/1/1991 Enroll Date: 4/3/04 POC Number: 6 --&~~ ::~v.. v Family Vision: To reunify the children with their mother and to maintain stability. Domains: Fanilly Saf1~ty Mental Health Start Date: 9/1/2004 Target Accomplish Date: 9/1/2005 Updates: 11/15/2004 This is where the CC types in updates on what's been going on with this particular need from POC to POCo Domains: Edu4;ational / Vocational Start Date: 1/1/2005 Target Accomplish Date: 1/1/2006 Page 7 of9 Date Printed: 2/7/2005 POC Date Domain Rating Cultural/Spiritual 6/13/ /27/ Educational/ Vocational 6/13/ /27/ /13/2004 1/27/2005 6/13/2004 1/27/2005 Family 2 3 Legal 3 4 Living Situation 6/13/ /27/2005 No Needs Identified 6/13/2004 1/27/2005 Medical 2 4 Mental Health 6/13/ /27/ /13/2004 1/27/2005 6/13/2004 1/27/2005 Other 1 3 Safety 2 3 Social/Recreational 6/13/ /27/2005 No Needs Identified Page 8 of9 Date Printed: 2/7/2005 POC Date 6/13/04 1/27/05 Score Domain Scores pac IJate 1/27f.!D05 Care Coordinator Aggie Hale Date 1/17/05 Supervisor Approval by Supv Appr Date CC Agency Wraparound Milwaukee Page 9 of9 Date Printed: 2/7/2005
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