Rehabilitative Services Monthly Progress Report




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C
DPP-1294

R. 12/2008


ommonwealth of Kentucky


Cabinet for Health and Family Services

Department of Community Based Services

Division of Protection and Permanency


Rehabilitative Services Monthly Progress Report
MONTH ENDING

DCBS CASE MANAGER ___________________________

CHILD NAME: DOB:

SSN NUMBER: PROVIDER/ FACILITY:



Date of Current DPP-1293 Approval: Date of Next Six Month Review:
MONTHLY FACE-TO-FACE CONTACT INFORMATION:


  1. Date of contact: ____/ __/20___




  1. Location of contact (check only one):




PCC facility




Independent living




Jail




PCC group home




Treatment facility




Other agency




PCC foster home




Hospital




Youth’s home




Adoptive home




Detention Center




Other resource




  1. Purpose of contact (check all that apply):




Progress on child/youth case plan




Foster home services




Progress on family level case objective




Placement services




Progress on individual level case objective




Sibling visitation




Services/issues not addressed in case plan




Parent and sibling visitation




  1. Service activity conducted (check all that apply):




Case coordination/management




Assessment




Complaints/disagreements against staff




Ongoing services




Counseling (individual)




Tracking/follow-up




Placement















  1. Description of service activity including but not limited to verification of Lifebook development, review of treatment plan (including supervision plan), review of medical passport, review of educational or developmental progress, and review of visitation agreement or permanency plan.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________



TREATMENT SUMMARY:

OVERALL GOALS / OBJECTIVES OF REHABILITATIVE SERVICES PLAN:


 DPP-1293 IN DEVELOPMENT

 Remains the same as described in the rehabilitative services plan of care, DPP-1293

 Have been changed as indicated on the attached revised DPP-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 PROVIDER ACTIVITY DESCRIPTION



______________________________________________
____________ ______________________________________________
______________________________________________
______________________________________________


  1. 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 PROVIDER ACTIVITY DESCRIPTION


______________________________________________
______________________________________________
______________________________________________
______________________________________________


  1. 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 PROVIDER 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), may be faxed or mailed

Copy—Facility / Provider File (if applicable)








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