Form 1 Individual Service Plan

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average .50 /hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
OMB Control No: 0970-XXXX; Expiration date: XX/XX/XXXX

UC Basic Information
First Name:
Last Name:
AKA:
Status:
Date of Birth:
A No.:
Age:
Country of Birth:

Gender:
LOS:
Current Program:
Admitted Date:
Individual Service Plan

Case Manager:
Clinician:
Mandatory Services
Service

Task

Frequency

Orientation

Program Orientation

One Time

Assessment

UC Assessment

One Time

Medical

Medical Exam w/in 48 Hours of

One Time

Start Date

End Date

Person Responsible

Admission
Education

Recreation and Leisure

Assessment

One Time

Plan

One Time

Classes

Daily

Large Muscle Activity and Leisure 1 hour of
Time

each/weekday;
5 hours
total/weekends

Individual Counseling

Session

Once Weekly

Group Counceling

Session

Twice weekly (or
once weekly with
community
meeting)

Access to Religious Services

Attendance

Up on request

Case Management

Discharge Planning;

Ongoing

Family Reunification

Once weekly
meetings with
UAC for updates

Legal Orientation

KYR Presentation;

One Time each

Legal Screening
Vocation

Training and Activities

Once weekly

Other Services
Service

Tasks

Frequency

Certificate
Signature:  
Print Name:

Date:
Title:

Start Date

End Date

Person Responsible