4
PLAN OF CARE
(Revised July 2011)
CHILD’S NAME: DATE OF MEETING:
D.O.B.: D.O.P.:
CARPE DIEM HOME: STATUS:
PLACING AGENCY: WORKER:
PERIOD COVERED:
FOSTER PARENT REPORT
STRENGTHS, APTITUDES AND ABILITIES:
·
SUMMARY OF SIGNIFICANT EVENTS (since last reporting period, i.e. court):
·
LIST OF RESOURCES (include who provides which services):
·
HEALTH (include allergies and adverse reactions):
·
Medication:Medical:
Weight:
Height:
Dental:
Other
OTHER APPOINTMENTS THIS PERIOD:
·
PLAN OF CARE (SMART Goals ~ Specific, Measurable, Attainable, Results Oriented, Timely)
Review of Previous Desired Outcome (from Last POC):
·
HEALTH DIMENSIONDESIRED OUTCOMES /
WORK REQUIRED
/ PERSON RESPONSIBLE / SPECIFIEDTIME FRAMES
EDUCATION:
·
PLAN OF CARE (SMART Goals ~ Specific, Measurable, Attainable, Results Oriented, Timely)
Review of Previous Desired Outcome (from Last POC):
·
EDUCATION DIMENSIONDESIRED OUTCOMES /
WORK REQUIRED
/ PERSON RESPONSIBLE / SPECIFIEDTIME FRAMES
IDENTITY:
·
PLAN OF CARE (SMART Goals ~ Specific, Measurable, Attainable, Results Oriented, Timely)
Review of Previous Desired Outcome (from Last POC):
·
IDENTITY DIMENSIONDESIRED OUTCOMES /
WORK REQUIRED
/ PERSON RESPONSIBLE / SPECIFIEDTIME FRAMES
FAMILY AND SOCIAL RELATIONSHIPS:
·
PLAN OF CARE (SMART Goals ~ Specific, Measurable, Attainable, Results Oriented, Timely)
Review of Previous Desired Outcome (from Last POC):
·
FAMILY & SOCIAL RELATIONSHIP DIMENSIONDESIRED OUTCOMES /
WORK REQUIRED
/ PERSON RESPONSIBLE / SPECIFIEDTIME FRAMES
SOCIAL PRESENTATION:
·
PLAN OF CARE (SMART Goals ~ Specific, Measurable, Attainable, Results Oriented, Timely)
Review of Previous Desired Outcome (from Last POC):
·
SOCIAL PRESENTATION DIMENSIONDESIRED OUTCOMES /
WORK REQUIRED
/ PERSON RESPONSIBLE / SPECIFIEDTIME FRAMES
EMOTIONAL AND BEHAVIOURAL DEVELOPMENT:
·
PLAN OF CARE (SMART Goals ~ Specific, Measurable, Attainable, Results Oriented, Timely)
Review of Previous Desired Outcome (from Last POC):
·
EMOTIONAL/BEHAVIOURALDIMENSION
DESIRED OUTCOMES /
WORK REQUIRED
/ PERSON RESPONSIBLE / SPECIFIEDTIME FRAMES
SELF-CARE SKILLS:
·
PLAN OF CARE (SMART Goals ~ Specific, Measurable, Attainable, Results Oriented, Timely)
Review of Previous Desired Outcome (from Last POC):
·
SELF-CARE DIMENSIONDESIRED OUTCOMES /
WORK REQUIRED
/ PERSON RESPONSIBLE / SPECIFIEDTIME FRAMES
INCIDENT REPORTS and/or SERIOUS OCCURRENCES:
·
______
FOSTER PARENT DATE
______
CASE MANAGER, SUPERVISOR, if applicable.
OR DESIGNATE.
9355 Dixie Road, Brampton, ON L6S 1J7 Tel: 905.799.2947 Fax: 905.790.8262 Email: