CSP in progress;  OR    Final CSP

Mayview Regional Service Area Plan Project

State Hospital Discharge Community Support Plan*

IDENTIFYING DATA		MEETING DATE:
Individual’s Name	Date of Birth		Age	Social Security Number
Marital Status	Race/Sex
SCU Number	Admission Date			Discharge Date
Role/Position	Signature (I agree to this plan and I am committed fulfilling my responsibilities as indicated in this plan)			Print Name

County person is moving to:

Who is responsible and accountable for supervision and oversight of the Community Support Plan?

Name:	Title:
Agency:	Phone #:

ASSESSMENT STAGE:

1.  CONSUMER ASSESSMENT SUMMARY

Strengths

Interests/Likes

Consumer’s Dislikes

2.  FAMILY ASSESSMENT SUMMARY

Strengths

Interests/Likes

Consumer’s Dislikes

3. Clinical Assessment / Worksheet

Consumer Strengths

Consumer Interests /Likes

Consumer Dislikes

Consumer Psychiatric and Behavioral Conditions to consider

Consumer Physical Conditions to consider

INFORMATION GATHERING STAGE:

TOPIC AREA #1:  RECOVERY SERVICES AND SUPPORTS IN THE COMMUNITY

TOPIC AREA #2:  LIVING ARRANGEMENTS / HOUSING

TOPIC AREA #3:  INSURANCE / BENEFITS / ENTITLEMENT

TOPIC AREA #4:  PHYSICAL HEALTH CARE

TOPIC AREA #5:  MENTAL HEALTH CARE

Follow-up items / person responsible / due date:

1. _

2. _

3. _

4. _

5. _

6. _

7. _

8. _

9. _

10. _

Date / time / location of next meeting: __
OPTIONS STAGE:

TOPIC AREA #1:  RECOVERY SERVICES AND SUPPORTS IN THE COMMUNITY

TOPIC AREA #2:  LIVING ARRANGEMENTS

TOPIC AREA #3:  INSURANCE / BENEFITS / ENTITLEMENT

TOPIC AREA #4:  PHYSICAL HEALTH CARE

TOPIC AREA #5:  MENTAL HEALTH CARE

Follow-up items / person responsible / due date:

11. _

12. _

13. _

14. _

15. _

16. _

17. _

18. _

19. _

20. _

Date / time / location of next meeting: __

TRANSITION STAGE:

TOPIC AREA #1:  RECOVERY SERVICES AND SUPPORTS IN THE COMMUNITY

TOPIC AREA #2:  LIVING ARRANGEMENTS

TOPIC AREA #3:  INSURANCE / BENEFITS / ENTITLEMENT

TOPIC AREA #4:  PHYSICAL HEALTH CARE

TOPIC AREA #5:  MENTAL HEALTH CARE

Follow-up items / person responsible / due date:

21. _

22. _

23. _

24. _

25. _

26. _

27. _

28. _

29. _

30. _

Date / time / location of next meeting: __

FINAL PLAN:

INSURANCE / BENEFITS  / ENTITLEMENTS
Insurance/ Benefits/ Entitlement:	SSI?		SSDI?	Amount				#
	Medicaid:			Medicare:
	Private Insurance:
	Medications Paid By:
	Food Stamps:      Section 8 Other Benefits:  Waiver:
Applications Filed & Follow-up Needed		Application			Follow-up action		Responsible Person
1) 2) 3)
Income		Amount $ _ every _ ___     Source:
Representative/ Guardian/Payee		Name
		Address
		Phone				Relationship

PHYSICAL HEALTH CARE (Upon Discharge Attach Medical History and Most Recent Blood Work and Labs)
Physical Health treatment Needed after Discharge	1. Type of Physician:	Name:
	Address/Location:
	Phone:
	2. Type of Physician:		Name:
	Address/Location:
	Phone:
	3. Type of Physician:		Name:
	Address/Location:
	Phone:
	Diagnoses:
	1.
	2.
	3.
	4.
	5.
	6.
	Medications & Dosage (List or attach)			Supply (# of days)
	Who will fill new supply?
Describe any special needs regarding physical health needs including medication administration, frequency of appointments, frequency of monitoring health concerns, etc.

Multi-Agency Special Needs	Note coordination of care, accommodations needed, assistive devices, etc.
Aging  Blind  Criminal Justice  Deaf  Hard of Hearing  Mental Retardation / Develop Disability	Physical Disability  Traumatic Brain Injury  Non-English Language  Other	Describe in detail what the consumer needs.
		List the following:
		Agency	Specific Need	Contact/#
Describe any additional needs or information regarding the above:

LIVING
Type of Residence   Permanent  Transitional	Own home/Apt		Shared home/Apt				Single room
	Personal Care Home		Community Residential Rehab				Fairweather Lodge
	Long Term Structured Residence			Supportive Housing
	Other
	Total number of persons in shared living situation:  _
Level of Independence	Living independ	Family Setting			Living Dependently
	Supervised Setting	Restrictive Setting			Living semi-independently
Address:
Agency: (If applicable)	Name of Agency					Phone #
Agency Contact:

MENTAL HEALTH CARE
Does the Consumer have a Psychiatrist in the community? (name)
Phone	Address
What is the Current Diagnosis (Axis I-V):
Community Treatment Needed		Type	Frequency	Provider/Contact Name/ #
		Outpatient/Group Content:
		Outpatient/Individual Content:
		Drug & Alcohol Content:
		Co-Occurring Services Content:
		Other:         Content:
		Other:         Content: