Transitional Indenpendent Living Plan & Agreement - California

Transitional Independent Living Plan & AgreementYouth:John CampanoDate of Birth: 11/14/92Age 15Ethnicity: HispanicAddress: 3456 Kramer Lane, Santa Paula, CA 90000Instructions To Youth: The purpose of this agreement is to capture the goals you are agreeing to achieve over the next 6months. It is a good organizing tool to help you stay focused and keep track of your progress toward accomplishing eachgoal. Your Social Worker/Probation Officer and caregiver will also have copies of this agreement and will help youachieve your success.Instructions to Caregiver: You are agreeing to assist the youth in the development of their ILP goals and to support theyouth in completing the activities.Instructions to Social Worker/Probation Officer: You are agreeing to assist the youth and the caregiver in completingthis form, and develop Planned Services that will assist the youth in meeting his/her goals. Document the PlannedServices and Delivered Services in CWS/CMS. Probation officers: use manual documentation procedures.Service goals and activities to be addressed in the plan:Goals are individualized based on your assessment and may include examples such as: develop a life-long connection to a supportive adultgraduate from high schoolobtain a part-time jobinvest savings from part-time jobdevelop community connectionsobtain a scholarship to attend collegedevelop competency in the life skill ofActivities are individualized to help meet a specific goal. Example – if high school graduation is a goal, the youth directedactivity might be to attend classes regularly with no tardies for the next 6 months.For youth participating in ILP services, activities are reportable as ILP Delivered Services in CMS. The social worker shallselect from one or more of the following ILP Service Types that an individualized completed activity fits in: Received ILP Needs AssessmentILP MentoringILP EducationILP Education Post SecondaryILP Education Financial AssistanceILP Career/Job GuidanceILP Employment/Vocational TrainingILP Money ManagementILP Consumer SkillsILP Health Care ILP Room and Board Financial AssistanceILP Transitional Housing, THP, THP PlusILP Home ManagementILP Time ManagementILP Parenting SkillsILP Interpersonal/Social SkillsILP Financial Assistance OtherILP TransportationILP Other (Stipends/Incentives)XI understand that if I am employed as part of this plan, my earned income will be disregarded, as thepurpose of my employment is to gain knowledge of needed work skills, habits and responsibilities tomaintain employment. (WIC 11008.15)XI understand that I can retain cash savings up to 10,000 under this plan in an insured savings account andany withdrawal requires the written approval of my social worker/probation officer and must be used forpurposes directly related to my transitional goals. (WIC 11155.5)XI understand that I will receive assistance to obtain my personal documents and information about financialaid for postsecondary education/training.(WIC 16001.9)State of CaliforniaDepartment of Social ServicesCWS Case Management SystemCS-ILPLAN REV (04-08)This document is based on sample found at http://calswec.berkeley.edu/CalSWEC/OtherTraining i.htmlCopies to: YouthCaregiverCase FileILPPage 1 of 213

Transitional Independent Living Plan & AgreementYouth:John CampanoDate of Birth: 11/14/92Case Worker Name: Frank RichardsAge 15Ethnicity: HispanicCase Worker phone: 800 -555-1234TILP 6-month timeline: 7/1/08 to 1/1/09 Date Independent Living Needs Assessment completed: 5/1/08X If I have not participated in the ILP program before, I agree to participate now.X Based on the assessment of my level of functioning, the following transitional goals and activities meet my current needs.GoalActivityGoal #1: Take on moreresponsibility for selfcare.1.With the assistance of the caregiverI will be doing my own laundrywith three months.Responsible PartiesPlannedCompletion dateJohn CampanoLisa Evergreen ( fosterparent)10/1/08John CampanoKeith Maine (tutor)1/1/09John CampanoLisa Evergreen (FP)Frank Richards(SW)Delia Veracruz(School Counselor)10/15/08John CampanoLisa EvergreenG----8/1/08(ILP Home Management)2.Goal #2: Improve mygrade in AlgebraI will work with my tutor in algebrathree times a week for one hour.(ILP Education).3.Goal # 3: Work in aveterinarian’s officeI would like to work part time in aveterinarian’s office. I will find outmore about how to become aveterinarian. I will meet with myschool counselor about what I cando to become a veterinarian.(ILP Career/Job Guidance)Goal #4: Socialize andbegin dating4.I would like to go on a groupdate to the movies, and will askG---- if she would like to comewith me by 8/1/08(ILP Interpersonal/Social Skills)Progress ReviewHeld: / /Met GoalDateSatisfactoryProgressNeeds moretime/assistance.Goal needsmodification.Met GoalDateSatisfactoryProgressNeeds moretime/assistance.Goal needsmodification.Met GoalDateSatisfactoryProgressNeeds moretime/assistance.Goal needsmodification.Met GoalDateSatisfactoryProgressNeeds moretime/assistance.Goal needsmodification.This Agreement will be updated on: 1/1/09 Update #Signing this agreement means we will all work to complete the steps necessary to help the youth reach his/hergoals.John CampanoYouth’s signature6/28/08DateLisa EvergreenCaregiver’s signature6/28/08DateFrank RichardsSocial Worker/Probation Officer signature6/28/08DateState of CaliforniaDepartment of Social ServicesCWS Case Management SystemCS-ILPLAN REV (04-08)This document is based on sample found at http://calswec.berkeley.edu/CalSWEC/OtherTraining i.htmlCopies to: YouthCaregiverCase FileILPPage 2 of 2

Transitional Independent Living Plan & AgreementYouth:John CampanoDate of Birth: 11/14/92Age 15Ethnicity: HispanicCase Worker Name: Frank RichardsCase Worker phone: 800 -555-1234TILP 6-month timeline: 7/1/08 to 1/1/09 Date Independent Living Needs Assessment completed: 5/1/08X If I have not participated in the ILP program before, I agree to participate now.X Based on the assessment of my level of functioning, the following transitional goals and activities meet my current needs.GoalGoal #1: Take on moreresponsibility for selfcare.Activity1.With the assistance of the caregiverI will be doing my own laundrywith three months.Responsible PartiesPlannedCompletion dateJohn CampanoLisa Evergreen ( fosterparent)10/1/08John CampanoKeith Maine (tutor)1/1/09John CampanoLisa Evergreen (FP)Frank Richards(SW)Delia Veracruz(School Counselor)10/15/08John CampanoLisa EvergreenG----8/1/08(ILP Home Management)Goal #2: Improve mygrade in Algebra2.I will work with my tutor in algebrathree times a week for one hour.(ILP Education).Goal # 3: Work in aveterinarian’s office3.I would like to work part time in aveterinarian’s office. I will find outmore about how to become aveterinarian. I will meet with myschool counselor about what I cando to become a veterinarian.(ILP Career/Job Guidance)Goal #4: Socialize andbegin dating4.I would like to go on a groupdate to the movies, and will askG---- if she would like to comewith me by 8/1/08(ILP Interpersonal/Social Skills)Progress ReviewHeld: 12/29/08X Met GoalDate12/3/08SatisfactoryProgressNeeds moretime/assistance.Goal needsmodification.Met GoalDateX SatisfactoryProgressX Needs moretime/assistance.Goal needsmodification.Met GoalDateSatisfactoryProgressNeeds moretime/assistance.X Goal needsmodification.X Met GoalDate7/16/09SatisfactoryProgressNeeds moretime/assistance.Goal needsmodification.This Agreement will be updated on: 1/1/09 Update #Signing this agreement means we will all work to complete the steps necessary to help the youth reach his/hergoals.John CampanoYouth’s signatureDateLisa EvergreenCaregiver’s signature6/28/08DateFrank RichardsSocial Worker/Probation Officer signatureState of CaliforniaDepartment of Social ServicesCWS Case Management SystemCS-ILPLAN REV (04-08)6/28/086/28/08DateCopies to: YouthCaregiverCase FileILPThis document is based on sample found at http://calswec.berkeley.edu/CalSWEC/OtherTraining i.html Page 2 of 2

Transitional Independent Living Plan & AgreementYouth:John CampanoDate of Birth: 11/14/92Age 16Ethnicity: HispanicAddress: 3456 Kramer Lane, Santa Paula, CA 90000Instructions To Youth: The purpose of this agreement is to capture the goals you are agreeing to achieve over the next 6months. It is a good organizing tool to help you stay focused and keep track of your progress toward accomplishing eachgoal. Your Social Worker/Probation Officer and caregiver will also have copies of this agreement and will help youachieve your success.Instructions to Caregiver: You are agreeing to assist the youth in the development of their ILP goals and to support theyouth in completing the activities.Instructions to Social Worker/Probation Officer: You are agreeing to assist the youth and the caregiver in completingthis form, and develop Planned Services that will assist the youth in meeting his/her goals. Document the PlannedServices and Delivered Services in CWS/CMS. Probation officers: use manual documentation procedures.Service goals and activities to be addressed in the plan:Goals are individualized based on your assessment and may include examples such as: develop a life-long connection to a supportive adultgraduate from high schoolobtain a part-time jobinvest savings from part-time jobdevelop community connectionsobtain a scholarship to attend collegedevelop competency in the life skill ofActivities are individualized to help meet a specific goal. Example – if high school graduation is a goal, the youth directedactivity might be to attend classes regularly with no tardies for the next 6 months.For youth participating in ILP services, activities are reportable as ILP Delivered Services in CMS. The social worker shallselect from one or more of the following ILP Service Types that an individualized completed activity fits in: Received ILP Needs AssessmentILP MentoringILP EducationILP Education Post SecondaryILP Education Financial AssistanceILP Career/Job GuidanceILP Employment/Vocational TrainingILP Money ManagementILP Consumer SkillsILP Health Care ILP Room and Board Financial AssistanceILP Transitional Housing, THP, THP PlusILP Home ManagementILP Time ManagementILP Parenting SkillsILP Interpersonal/Social SkillsILP Financial Assistance OtherILP TransportationILP Other (Stipends/Incentives)XI understand that if I am employed as part of this plan, my earned income will be disregarded, as thepurpose of my employment is to gain knowledge of needed work skills, habits and responsibilities tomaintain employment. (WIC 11008.15)XI understand that I can retain cash savings up to 10,000 under this plan in an insured savings account andany withdrawal requires the written approval of my social worker/probation officer and must be used forpurposes directly related to my transitional goals. (WIC 11155.5)XI understand that I will receive assistance to obtain my personal documents and information about financialaid for postsecondary education/training.(WIC 16001.9)State of CaliforniaDepartment of Social ServicesCWS Case Management SystemCS-ILPLAN REV (04-08)This document is based on sample found at http://calswec.berkeley.edu/CalSWEC/OtherTraining i.htmlCopies to: YouthCaregiverCase FileILPPage 1 of 2