Department for social services rehabilitative services plan of care approval form




Yüklə 6.22 Kb.
tarix11.03.2016
ölçüsü6.22 Kb.
DSS-1293 (Rev. 9/02)
DEPARTMENT FOR SOCIAL SERVICES

REHABILITATIVE SERVICES

PLAN OF CARE APPROVAL FORM

Child Name: Plan of Care Status:

Date of Birth:  New plan, requesting approval

SSN Number:  Initial six-month review, requesting re-approval

 Follow-up 6 month review, requesting re-approval

Presenting problems:


Diagnostic impression or DSM IV diagnosis :
 depression, dysthymia  post traumatic stress disorder  oppositional defiant disorder

 conduct disorder  adjustment disorder  attention deficit disorder

 child abuse/neglect  child or adolescent anti-social behavior  other:
Summary of rehabilitative goals/objectives:


Rehabilitative services, activities that are to be provided, based on needs of child ( check all that apply) :
 treatment planning/support  living skills development  counseling, therapy, consultation, assessment
Please specify services to be provided :
Need for services approved by :

PRINT name and title Signature
Effective Date of Plan:
COPY TO :
1. Family Services Worker : 2. Facility/Provider : _________________

DSS Office : _____________________________________ Address : _____________________________________ City/State/Zip: __________________________________

City/State/Zip: __________________________________ Telephone/Fax: ________________________________

Telephone/Fax: _________________________________


3. TCM/Rehab Coordinator, Resource Management Section 3C-D, CFC Bldg, 275 E. Main, Frankfort, KY 40621


Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©azrefs.org 2016
rəhbərliyinə müraciət

    Ana səhifə