Monthly progress report




Yüklə 12.17 Kb.
tarix11.03.2016
ölçüsü12.17 Kb.


DSS-1294 (REV. 9/02) MONTH ENDING
DEPARTMENT FOR SOCIAL SERVICES

REHABILITATIVE SERVICES

MONTHLY PROGRESS REPORT
CHILD NAME: DOB:

SSN NUMBER: PROVIDER/ FACILITY:

Date of Current DSS-1293 Approval: Date of Next Six Month Review:
TREATMENT SUMMARY:

OVERALL GOALS / OBJECTIVES OF REHABILITATIVE SERVICES PLAN:


 DSS-1293 IN DEVELOPMENT
 Remains the same as described in the rehabilitative services plan of care, DSS-1293
 Have been changed as indicated on the attached revised DSS-1293
PROGRESS NOTES:

1. TREATMENT PLANNING AND SUPPORT- Describe representative treatment planning and support activities performed over the last month in support of the Goals and Objectives of the Rehabilitative services plan of care:

DATE ACTIVITY DESCRIPTION




2. LIVING SKILLS DEVELOPMENT - Describe representative skills training and development activities performed over the last month in support of the Goals and Objectives of the rehabilitative services plan of care:

DATE ACTIVITIES DESCRIPTION





3. THERAPY, EVALUATION AND ASSESSMENT- Describe Counseling, Therapy, Evaluation and Assessment activities performed over the last month in support of the goals and objectives of the rehabilitative services plan of care:


DATE ACTIVITY DESCRIPTION





CASE STATUS SUMMARY ( APPLIES ONLY TO PRIVATE CHILD CARE PROVIDERS)
1. SUMMARIZE CHILD’S ADJUSTMENT TO FACILITY:

2. SERVICES PROVIDED TO CHILD AND CHILD’S FAMILY:

3. PROGRESS TOWARD RETURN OF CHILD TO THE HOME OR COMMUNITY ( IF APPLICABLE):

4. PERMANENCY GOAL FOR CHILD:

NAME AND TITLE OF PERSON COMPLETING FORM:

( PLEASE PRINT)


SIGNATURE:
SUPERVISOR’S NAME AND SIGNATURE (IF REQUIRED):

DISTRIBUTION: Original- Child’s Family Services Worker (case record)

Copy- Facility / Provider File ( if applicable)

Copy- TCM / Rehab Coordinator, Child Placement Support Section 3C-D, CFC Bldg,



275 East Main, Frankfort, Ky. 40621



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

    Ana səhifə