Exhibit II - Personalized Service Plan.pdf

PDF 168 KB Posted Jun 1, 2024

Attached to: Master Agreement AZ|CTR071420
Contract number: CTR071420
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 (DCS), designed as a comprehensive template for tracking and managing care for children in group home settings. The form is Exhibit II, dated October 2023, and is intended to document detailed information about a child's placement, including personal contacts, educational status, therapy and visitation schedules, and individualized care goals.

The document provides a structured approach to recording critical information across multiple domains, including child and facility details, important contacts, visitation rights, educational requirements, therapy schedules, extracurricular activities, and personal development goals. The form includes sections for tracking the child's progress in areas such as permanence and independence, community and culture, self-care and health, identity, and social life. It also includes space for final considerations like probation/parole status, health considerations, discharge planning, and plan participants, with provisions for documenting invitations, attendance, and signatures of key stakeholders involved in the child's care plan.

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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.