CLIENT INDIVIDUALIZED CARE PLAN
CLIENT INDIVIDUALIZED CARE PLAN
Client Name: _____________________________________ Date Assessment Completed: _____________ Date Plan Begins: ___________
Case Manager Assigned: _________________________________ Case Management Agency:__________________________________
|# |IDENTIFIED |GOALS/OBJECTIVES & DESIRED OUTCOME |REALISTIC TIME FRAME |DATE OUTCOME MET |BARRIERS IF APPLICABLE |
| |NEED/ PROBLEM |(Action Steps) | | | |
| | | | | | |
| | | | | | |
| | | | | | |
| | | | | | |
Client’s Statement and Agreement: I have participated in the creation of this plan for my care. I understand that I have to take responsibility for MY plan in order for the plan to succeed. The case manager has explained to me what portions of this plan I am solely responsible for and those that my case manager will assist me with. I agree to follow all aspects of this plan and advise my case manager if there are significant changes in my life that makes it necessary to change my plan. I agree to stay in contact with my case manager as planned.
Client Signature: __________________________________________________ Date Plan Was Implemented: ___________________
Case Manager Signature: ___________________________________________ Re-evaluation Date: ______________________________
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