Exhibit II - Personalized Service Plan.pdf

PDF 168 KB Posted Jun 1, 2024

Attached to: Master Agreement AZ|CTR071428
Contract number: CTR071428
Issued by: Arizona

About this file

Written by GovTribe AI · Sep 25, 2025

This document is a Congregate Care Personalized Service Plan from the Arizona Department of Child Safety, dated October 2023. It is a comprehensive form designed to document and track the care, education, and personal development of a child or youth in group home care. The form is part of Exhibit II and covers multiple aspects of a child's life, including personal information, contacts, visitation schedules, therapy, education, and personal goals.

The form is structured to capture detailed information about the child's current situation, including school details, extracurricular activities, personal goals across various life domains (such as independence, community and culture, self-care, health, identity, and social life), and final considerations for discharge and aftercare. It provides spaces for tracking the child's progress, identifying areas where they need support, and documenting who will help them achieve their goals. The document is designed to be a comprehensive planning and tracking tool for child welfare professionals to ensure holistic support for children in congregate care settings.

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CONGREGATE CARE

PERSONALIZED SERVICE PLAN

ARIZONA DEPARTMENT OF CHILD SAFETY

Exhibit II (10/23)

Group Home Name and Facility

DCS Supervisor's Name

Probation/Parole Name

RHBA Contact Name

Contacts

City

Phone

PhoneRelationship

House Phone

Phone

PhoneRelationship

Age

State Zip

Date to ReviewDate CompletedDate of Placement

Case ID

Child’s Information

Important People: (parents, siblings, grandparents/other relatives, friends, etc.)

Child/Youth (Last, First, M.i.)

DCS Specialist's Name

Group Home Staff Member Name

Physician’s Name

Contacts

Date of Birth

Site Address

*Reasonable and Prudent Parenting Standard

ARIZONA DEPARTMENT OF CHILD SAFETY

Exhibit II (10/23)

Visitation Schedule (include approved and restricted persons)

Therapy Schedule

Details

Relationship

Name

Details (location; type)

AttendedDate

Attended

Date

AttendedDate

Attended

Date

Attended

Date

Details (location; type)

Missed (details why)

Yes

ARIZONA DEPARTMENT OF CHILD SAFETY

Exhibit II (10/23)

Standing Appointments

Details

Relationship

Name

Yes NoIs there a Crisis Plan?

Education

Group Home Name and Facility

School Nurse

School Counselor

City

School Hours

Phone No.

Grade

State Zip

Case IDSchool Name

Location of plan (if applicable):

Phone No.

School Address

Middle School

Other

Pick-up and Drip-off Times

Elementary

High School

Teacher

PhoneSubject/Class

Teacher

Teacher and Class Information

ARIZONA DEPARTMENT OF CHILD SAFETY

Exhibit II (10/23)

Education ~continued

Educational Goals

Educational Requirements

Educational Concerns

Extracurricular/After-school Activities (what you are doing or would like to do includes sports, employment, volunteering)

Activity Name

Schedule

Enrolled

Transportation

ARIZONA DEPARTMENT OF CHILD SAFETY

Exhibit II (10/23)

My plan/goal Timeframe (by when?) I am good at I need help with Who will help & how

Permanence and Independence

Community & Culture

Self Care & Health

Identity

Social Life &Friendships

Other

Personal Goals

ARIZONA DEPARTMENT OF CHILD SAFETY

Exhibit II (10/23)

Final Considerations

Plan Participants

Probation/Parole Considerations

Health/Other Considerations

Discharge/Aftercare services

Approximate Discharge Date

At a minimum, Please list those participants required in the Scope of Work and Child Welfare Licensing Rules.

Name Role Invited Attended Signature Date

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File details come from the government source that posted it. Updated Sep 25, 2025.