2. Date/Time:
   Date/Time:

   Date/Time:
3. Date of last review:*
   Date of last review:

   Date of last review:
5. Client Name:*
6. Date of Birth:
   Date of Birth:
7. Legal Guardian:
   *if changed since last review
9. Address **Only fill out if address has changed since last review**
11. City
12. State
13. Zip Code
15. Case Manager's Name:*
16. Agency:*
    -- Select One --Northland Counseling CenterNorth HomesRoss Resources
18. ICHHS ROI Date:
19. Date of Last Functional Assessment:*
20. Date of Last Community Support Plan:*
21. Date of current Diagnostic:*
23. Current Diagnosis: *
24. Open Child Protection Case:*
    -- Select One --YesNo
25. If open CP case: Who is the Social Worker
27. Current Services: Check all that apply*

    1. CADI
    2. Rep-Payee
    3. CTSS
    4. Therapy
    5. Medication Management

    1. DBT
    2. Respite
    3. CD Services
    4. Other
28. If Other Services:
    Please list the other services.
30. MS 245.4871 subd. 3
    Case Management Service: means activities that are coordinated with the family community support service and are designed to help the child with severe emotional disturbance and the child’s family obtain needed medical health services, social services, educational services, health services, vocational services, recreational services and related services in the area of volunteer services, advocacy, transportation and legal services. Case management services include assisting in obtaining a comprehensive diagnostic assessment, if needed, developing a functional assessment, an individual community support plan and assisting the child and the child’s family in obtaining needed services by coordination with other agencies and assuring continuity of care. Case managers must assess and reassess the delivery, appropriateness and effectiveness of services over time.
32. Needed Referrals to Community Supports (not currently in place):*
34. Consumer update, progress, and plan for next 6 months: *
36. Plan of how to exit case management services:*
38. Upload any additional documentation:
39. Upload any additional documentation:
40. Upload any additional documentation:
41. Upload any additional documentation:
43. Items to remember:
    • Initial CM referral FA/ LOCUS/ ICSP sent to ICHHS within 30 days of intake • DA submitted to ICHHS every 3 years, or as often as DA is updated • New client will be reviewed with ICHHS at 6 months • FA/ ICSP/ LOCUS/ submitted to ICHHS every 6 months • ROI's submitted yearly • Yearly review will be scheduled with ICHHS • Agencies will complete and internal review and forward the review form to ICHHS
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