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?

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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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.

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