FFY2017 Promoting Safe and Stable Families Program

Form #4 - SERVICES & SERVICE DELIVERY

SoN #
Agency Name: / Program ID#
Program Name: / Service Model
Instructions:

Complete each section as directed.
Complete one “S” form for each proposed service.
Complete “S1” for intake assessment only.
Complete “S2” for case management only.
Number and complete “S” forms for every other required and/or additional services on the service plan.

Use “S” number to identify corresponding service when completing Service Delivery Schedule, Form #5.
Boxes will expand as you type.
Save as a pdf and identify as “son####_Services”.

S1 / Service/Activity. INTAKE ASSESSMENT . Required
Assessment at intake is a process by which information gathered, analyzed, and synthesized to determine strengths and needs of the family, parent or child to identify appropriate services and to develop an individual service plan. At intake, assessments should examine, at a minimum, the risk/stress factors that contribute to or put children at risk of neglect or maltreatment and impair family functioning. The assessment at intake may be supplemented with additional assessments or screening tools that evaluate the special characteristics or needs of the target population in order to develop a comprehensive and effective service plan. Instruments used may assess for risk, safety, child and family functioning, and trauma.
Based on the results of the assessment completed at intake, or results of an assessment conducted by referring agency, an individualized service plan must be developed that outlines service needs, desired goals for the family and defines in detail how those goals are to be achieved and measured. Goals should reflect identified priorities and must be realistic with attainable and measurable outcomes and timeframes for completion.
For CASA programs, this assessment includes the collection of information from all sources, preparation of the report, and all collateral contacts and court appearances up to and including the presentation of the findings to the court.
Throughout the life of a case or at case closure, other assessments may be conducted to monitor and evaluate progress. Complete “S” form for these additional assessments and screening services.
Description:

Provide a comprehensive description of your assessment process at intake to determine family (case specific) service needs, goals and priorities.Identify assessment and screening instruments used and their purpose.
How will the results from the intake assessment be used to monitor and assess progress and the effectiveness of services?
If information from an assessment conducted by another agency is used, describe who conducts the assessment, identify the assessment instruments used, and how the results of the assessment are used to develop the service plan.

a.
b.
c.
Duration and Number of Intake Assessments:

How long does it take to complete the intake assessment (gather information, analyze and develop a service plan)? (1/2 hour, 4 hours, etc.) Is the assessment conducted over more than one session? If so, how many? Please note: If time to complete the assessment and develop the individual service plan is variable) (ie. 3-4 hours), you will use the average or mid-range to complete your Service Delivery Schedule (in this case it would be 3.5 hours).
How many intake assessments do you anticipate conducting/completing during the year? What is this number based on?

a.
b.
Location: Identify where assessment occurs. Check one. If offered at any location other than the client’s home or the agency’s site, describe where and explain why.
In the home / At agency location / Other community site.
Explain:
Participants. Identify family members or individuals included in the intake assessment process. If “other” identify who and explain why.
Adult Caregivers
 Family: Adult Caregiver(s) & Child(ren) /  Youth only
 Child only /  Other.
Explain:
Identify Individuals Conducting/Completing Assessments.
Identify by name and/or title/position individual(s) conducting/completing the intake assessment. If several individuals are responsible for different elements of the assessment process, identify their role. (ie. conducts the interview, analyzes the results, prepares the report, reviews results with the family and develops the plan, etc.). Include:

Qualifications, education, and experience
Special training/certification required to conduct
Length of employment/history with agency

If position has not been filled, identify and describe recruitment plan.
Staff
Volunteers
Contractor (individuals)
Subcontractor (agency)
S2 / Service/Activity. CASE MANAGEMENT . Required
Case Management: All proposals are expected to demonstrate effective engagement with families in the collaborative process of identifying, planning, accessing, advocating for, coordinating, monitoring and evaluating resources, supports and services as outlined in the individual family service plan. This includes:
a)Service Coordination: Service coordination not only includes initiation of services but also monitoring and coordinating services and continuously assessing risk, assessing the services themselves, revising the plan as needed, and phase out of services. This includes:

Engaging with family in an on-going information-gathering and decision-making process to help identify their goals, strength and challenges
Collaborating with the family to plan and implement services with specific attainable, measurable objectives
Monitoring, evaluating and amending individualized service plans
Evaluating resources, supports and services
Documentation of all consultations with family, plan revisions, facilitated access to community resources, informal or formal supports, collaboration and communication with referral sources regarding family engagement and/or progress

b)Information & Referral: Families need assistance in identifying and accessing community-based resources to meet basic needs and to improve and sustain outcomes. This includes formal and informal supports, community resources, services, and opportunities. Service providers must think strategically about how an existing array of services might be augmented to form a continuum of supports and services for families that emphasize prevention of behavioral, emotional, and social problems, including child abuse and neglect, juvenile delinquency, and family violence. This may also include school-linked services to help parents support their child's education, health, growth, and development.
c)Advocacy: Advocating for the rights, decisions, strengths and needs of family and promoting client access to resources, supports and services. This includes modeling behavior that helps families learn to advocate for themselves and negotiate with service systems to obtain needed help and may include:

Providing education to family members and to others involved in the systems serving the family and children youth
Being a mediator by helping to educate professionals on the strengths and needs of the family
Helping family members understand the different roles of the agencies involved and how they may affect the family
Accompanying or representing the interests of the caregiver/child at IEPs, FTMs, MDTs, or DFCS case staffing, as needed

Indicate case management elements that will be provided. Check all that apply. You do not have to provide all.
 Service Coordination /  Information & Referrals /  Advocacy
How much case management will be provided per case per month to support service plan?
Describe how you will monitor and evaluate the effectiveness of your case management activities.
Individuals Providing Case Management
Identify by name and/or title/position individual(s) providing case management. Include:

Qualifications, education, and experience that qualifies them to provide case management
Length of employment/history with agency

Staff
Volunteers
Contractor (individuals)
Subcontractor (agency)

Copy, paste and number the following blank “S” form as needed.

Must have one “S” form for each service listed on the Service Delivery Schedule.

Complete one “S” form for all other required and additional service identified on the service plan beginning with “S3”. Complete required services first.
If service has specific and variable service delivery (ie. different population - children or adults, different intensity - one hour or two hour, different format - life skills for individuals or life skills for groups), complete its own “S” form.

Use “S” number to identify corresponding service when completing Service Delivery Schedule.

S_ /  Required
Service/Activity. Identify service or activity. Indicate if it is a required or additional service.  Additional
Description. Provide a comprehensive description of this service. Include all key elements and essential components. Be specific.
Service Objective(s). Describe the results you expect to achieve/the impact you expect this service to have on clients by the time case closes. Objectives should be “SMART”. See Section E. Resources for information on writing “SMART” objectives.
Outcome Measure(s). Describe how you will measure the impact of this service on clients to know whether service had the desired results.(Measurable component of the SMART objectives identified above)
Participants. Identify and describeindividuals to whom this service will be provided or who will be engaged in this activity. Be specific. Do not use general target population descriptions.
 Adult Caregivers Youth  Child(ren)
Individuals Providing Service. Identify by name and/or title/position individual(s) providing this service. Include:

Qualifications, education, and experience
Special training/certification required to provide this service
Length of employment/history with agency

If position has not been filled, identify and describe recruitment plan.
Staff
Volunteers
Contractor (individuals)
Subcontractor (agency)
Format: Describe service delivery. Choose one. If service is a group activity, indicate expected # of participants per group. If provided in “other” format, describe format and explain.
 Individual
Family
Group. Expected number of participants in group: ______
Other. Describe:
Duration: What is the average length of a single session (1/2 hour, 4 hours, etc.)? If the session length is not fixed, indicate range (2-3 hours). Please note: You will use the average or mid-range to complete your Service Delivery Schedule.
Frequency: Describe how often service will be provided (ie. weekly, twice a week, once a month, three times a year).
Length of time service will be provided: Describe period of time over which service will be provided (ie. six weeks, six months).
If offered multiple times, describe how many times the service will be offered during the year.(ie. two 6-week sessions per year).
Location: Identify where the proposed service will be provided. Choose one. If offered at any location other than the client’s home or the agency’s site, describe where and explain why. If provided in more than one location, explain why and the expected benefit.
In the home
At agency location
Other community site. Explain.
Additional Information. Use this space to provide additional information relevant to this service delivery.

Form #4B