Exhibit IV Individualized Service Plan.doc
DOC document 91 KB Posted
- Attached to
- AZ|CTR078811
- Contract number
- CTR078811
- Issued by
- Arizona
About this file
This document is an Individualized Service Plan (ISP) from the State of Arizona Department of Child Safety, located in Phoenix, Arizona. The form is designed to capture comprehensive information about a child or youth in the state's care, with sections for personal details, important contacts, education, goals, and service planning.
The document does not represent a traditional contract award or procurement document, but rather serves as a detailed planning tool for child welfare services. It includes sections for tracking the child's educational status, personal goals, health considerations, extracurricular activities, and support network. The form is structured to help case workers, social workers, and other involved parties create a holistic plan for the child's care, development, and potential future transition, with spaces to document key information such as school details, medical contacts, visitation schedules, and discharge planning.
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Text version
Exhibit IV State of Arizona
Department of Child Safety
Office of Procurement
3003 N. Central St, 20th Fl.
Phoenix, AZ 85012
Individualized Service Plan
Date Completed: ______________
Date to Review: ______________ Child/Youth's Name:
| DOB/Age: |
| Case ID: |
Group Home Name:
RPPS Contact* (Name/Phone/email):
House Address:
House Phone:
DCS Specialist's Name:
Phone/Email:
| DCS Supervisor's Name: |
| Phone/Email: |
| Probation/Parole Name: |
| Phone/Email: |
Physician’s Name
Phone/Email
RHBA Contact Name
Phone/Email
* Reasonable and Prudent Parenting Standard Important People: (parents, siblings, grandparents/other relatives, friends, etc.)
Who
(name/relationship) Phone/email
Visitation Schedule Who
Details
Standing Appointments:
Who
Details
Crisis Plan?
_______Yes
________No Location of plan (if applicable): _______________________________
Education I am in ______grade I attend: _______________________________________________________
□Elementary
□Middle School □High School □Other: _________________________
School Nurse (name & phone/email): ___________________________________________________________________________________________________
School Counselor (name & phone/email): _______________________________________________________________________________________________
| Teacher(s) |
| Subject/Class |
| Phone/email |
Extracurricular/After-school Activities: (what you are doing or would like to do)
| Activity Name |
| Enrolled: Y/N |
| Schedule |
| Transportation |
Personal Goals
| My plan/goal |
| Timeframe (by when?) |
| I am good at: |
| I need help with: |
| Who will help & how: |
Permanence
(family and positive adults in my life)
Education
Community & Culture
Self Care & Health
Identity
Social Life &Friendships
Other
Probation/Parole Considerations: ____________________________________________________________________________________________________
Health/Other Considerations: _______________________________________________________________________________________________________
Approximate Discharge Date: ____________ Discharge/Aftercare services_________________________________________________________________
PLAN PARTICIPANTS
| Name |
| Role |
| Invited |
| Attended |
| Signature/Date |
8/10/2016
File details come from the government source that posted it. Updated .