Preble Street TCM Service Plan
MAINEHOUSING HOUSING STABILITY PLAN (HSP) OR PLAN OF CARE (POC)
Date: ______________________
HOUSING STABILITY PLANS MUST BE REVIEWED AND UPDATED AT LEAST EVERY 30 DAYS AND REWRITTEN AT LEAST EVERY 90 DAYS.
Review Type: θInitial HSP/POC (or update) θ30 Day θ60 Day θ90 Day
Next Review Date: ____________________
Next Update: _________________________
Head of Household (HOH): _____________________________________
Other Household members: __________________________________________
_____________________________________________________________
Navigator/Case Worker: ______________________________
Phone: ___________________________________________________
Email: ___________________________________________________
Thinking about your income, housing, health (physical, mental, social), transportation, educational and legal needs, what resources do you need to achieve permanent housing stability?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
----------------------------------------------------------
Navigator Use for STEP Clients Only:
3, 6 and 9 Month Review Documentation (attach to HSP):
-DHHS Release of Information
-Income Verification
Recommendation to continue STEP (every 90 days): θYES θNO
If no, please provide documentation supporting the discontinuation of STEP
Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________
Navigator Signature & Date
θ Health Needs & 90 Day Goal:
_______________________________________________________________________________________________________________________________________________________________________________________
Strengths to achieve goal: _________________________________________________________
Barriers to achieve goal: __________________________________________________________
Presenting problem: Long Term Goals:
θ No health insurance θ Obtain health insurance
θ Need Physician θ Consistent Medical Care
θ Need Dentist θ Sobriety
θ Have health problems θ Emotional stability
θ Substance Use Short term Goals:
θ Need Mental Health services θ Apply for MaineCare
θ _______________________________________ θ Find a PCP
θ _______________________________________ θ Find a dentist
θ _______________________________________ θ Resolve health problems
θ _______________________________________ θ Reduce substance use
θ _______________________________________ θ Enter treatment/detox
θ Access MH services
θ ___________________
θ ___________________
Target Date: ____________ θ ___________________
θ ___________________
Navigator/Case Worker Responsibilities (connection to mainstream resources):
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Household Responsibilities and Activities:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________30 Day Update: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
60 Day Update:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
90 Day Update (were goals achieved why or why not, next steps):
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
Date Achieved or Discontinued: _____________
θ Educational Needs & 90 Day Goal: Highest level of education_____
_______________________________________________________________________________________________________________________________________________________________________________________
Strengths to achieve goal: _________________________________________________________
Barriers to achieve goal: __________________________________________________________
Presenting problem: Long Term Goal
θ Need more schooling to become employable θ Get GED
θ Reading ability θ Achieve HS Diploma
θ Learning disability_____________________________ θ College/Tech School
θ Other________________________________________ Short term Goals
θ Other________________________________________ θ Tutoring
θ Other________________________________________ θ Take GED Tests
θ Other_________________________________________ θ Enroll In School
θ _____________________
Target Date: __________________
Navigator/Case Worker Responsibilities (connection to mainstream resources):
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Household Responsibilities and Activities:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________30 Day Update: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
60 Day Update:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
90 Day Update (were goals achieved why or why not, next steps):
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
Date Achieved or Discontinued: _______________
θ Social Needs & 90 Day Goal:
_______________________________________________________________________________________________________________________________________________________________________________________
Strengths to achieve goal: _________________________________________________________
Barriers to achieve goal: __________________________________________________________
Presenting problem: Long Term Goal
θ Family_______________________________________ θ Stable Relationships
θ Partner_______________________________________ θ Stable Social Supports
θ Friends_______________________________________ Short term Goals
θ Other_________________________________________ θ Re-engage with family
θ Other_________________________________________ θ Re-engage with partner
θ Other_________________________________________ θ Develop Social Supports
θ _____________________
θ _____________________
Target Date: ________________ θ _____________________
Navigator/Case Worker Responsibilities (connection to mainstream resources):
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Household Responsibilities and Activities:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________30 Day Update: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
60 Day Update:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
90 Day Update (were goals achieved why or why not, next steps):
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
Date Achieved or Discontinued: ________________
θ Housing Needs & 90 Day Goal:
_______________________________________________________________________________________________________________________________________________________________________________________
Strengths to achieve goal: _________________________________________________________
Barriers to achieve goal: __________________________________________________________
Presenting problem: current living situation Long Term Goal
θ Shelter θ Stable housing
θ Couch Surfing Short term Goals
θ Place unsuitable for human habitation θ Secure Subsidies
θ Unstable Housing θ Transitional Housing
θ Hotel/Motel θ SRO
θ Pending eviction/loss of housing θ Return Home to Family
θ Left program, jail, foster care, other ________________ θ Enter Residential Program
θ Kicked out of/left home θ _____________________
θ Other_________________________________________
Target Date: _________________
Navigator/Case Worker Responsibilities (connection to mainstream resources):
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Household Responsibilities and Activities:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
30 Day Update: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
60 Day Update:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
90 Day Update (were goals achieved why or why not, next steps):
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
Date Achieved or Discontinued: _______________
θ Financial Needs & 90 Day Goal
_______________________________________________________________________________________________________________________________________________________________________________________
Strengths to achieve goal: _________________________________________________________
Barriers to achieve goal: __________________________________________________________
Presenting problem: Long Term Goal
θ Unemployed θ Stable Employment
θ Under Employed θ Stable Income
θ Lack Skills/Training Short term Goals
θ No work Experience θ Vocational Training
θ Negative Work History θ Part Time Job
θ No Income/Unemployable θ Gain Experience
θ Other_________________________________________ θ Apply for Entitlements
θ Volunteer
Target Date: ________________ θ _____________________
Navigator/Case Worker Responsibilities (connection to mainstream resources):
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Household Responsibilities and Activities:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________30 Day Update: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
60 Day Update:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
90 Day Update (were goals achieved why or why not, next steps):
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
Date Achieved or Discontinued: _____________
θ Transportation Needs & 90 Day Goal:
_______________________________________________________________________________________________________________________________________________________________________________________
Strengths to achieve goal: _________________________________________________________
Barriers to achieve goal: __________________________________________________________
Presenting problem: Long Term Goal
θ No transportation θ Stable form of transportation
θ ________________________________ Short term Goals
θ ________________________________ θ Access public transportation
θ _________________________________ θ Access ride for medical appointments
θ Maintain personal vehicle
θ _________________________________
Target Date: _____________ θ _________________________________
Navigator/Case Worker Responsibilities (connection to mainstream resources):
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Household Responsibilities and Activities:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________30 Day Update: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
60 Day Update:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
90 Day Update (were goals achieved why or why not, next steps):
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
Date Achieved or Discontinued: _____________
θ Legal Needs & 90 Day Goal:
_______________________________________________________________________________________________________________________________________________________________________________________
Strengths to achieve goal: _________________________________________________________
Barriers to achieve goal: __________________________________________________________
Presenting problem: Long Term Goal
θ _________________________________ θ _________________________________
Short term Goals
θ _________________________________
θ _________________________________
θ _________________________________
θ _________________________________
θ _________________________________
θ _________________________________
Target Date: _______________
Navigator/Case Worker Responsibilities (connection to mainstream resources):
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Household Responsibilities and Activities:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________30 Day Update: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
60 Day Update:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
90 Day Update (were goals achieved why or why not, next steps):
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
Date Achieved or Discontinued: _______________
θ Other ____________________:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Strengths to achieve goal: _________________________________________________________
Barriers to achieve goal: __________________________________________________________
Presenting problem: Long Term Goal
θ _________________________________ θ _________________________________
Short term Goals
θ _________________________________
θ _________________________________
θ _________________________________
θ _________________________________
θ _________________________________
θ _________________________________
Target Date: _______________
Navigator/Case Worker Responsibilities (connection to mainstream resources):
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
Household Responsibilities and Activities:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________30 Day Update: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
60 Day Update:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
90 Day Update (were goals achieved why or why not, next steps):
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
Date Achieved or Discontinued: ________________
EXIT PLANNING: Maintaining Permanent Housing
Long-Term resources that will be helpful and/or necessary to maintaining housing:
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
If my housing becomes unstable, I will contact:
______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
The above Housing Stability Plan/Plan of Care was developed in partnership with my Navigator/Case Worker. I understand that each action item listed above will support my efforts in securing permanent housing. I agree to work on this plan in partnership with my Navigator/Case Worker. I will update my Navigator/Case Worker as I complete the above goals. I will also communicate with any challenges I experience and understand my Navigator/Case Worker can offer me support as need.
Initial (or Update) Housing Stability Plan/Plan of Care:
Head of Household Signature _____________________________ Date ___________
Navigator/Case Worker Signature_________________________ Date ___________
30 Day Review:
Navigator /Case Worker Signature _________________________Date ___________
60 Day Review:
Navigator /Case Worker Signature _________________________ Date ___________
90 Day Review:
Head of Household Signature _____________________________ Date ___________
Navigator Signature/Case Worker__________________________ Date ___________
θ Collateral Contact – Sharing information between staff and with outside agencies will take place if helpful to the client in achieving continuity of care, coordination of services, and the most appropriate mix of services for the client.
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- customer service plan example
- customer service plan sample
- service plan company
- sample service plan for client
- customer service plan pdf
- excellent customer service plan sample
- client service plan examples
- sample customer service plan template
- customer service plan template free
- social work service plan sample
- social work service plan template
- customer service plan template