SERVICE AND BI-WEEKLY PLAN/INDEPENDENT LIVING PLAN FOR FAMILIES

BRONX FAMILY RESIDENCE
TODAY”S DATE:  01/20/00                                                                                                         (FACILITY NAME) 

CLIENT NAME:       SAM  FOSTER               APT #   2H        INITIAL SERVICE /INDEPENDENT LIVING PLAN   [X]         BI-WEEKLY REVIEW              DATE OF ADMISSION:      JANUARY 19, 2000

OTHER ADULT:       TRACY  FOSTER              FAMILY COMP: [2] /[2]             PA/HRA#  101010101010               S.S.#   000-00-0000                    OTHER# _____________________________

P.A. STATUS:  OPEN  [X]     CLOSED        PEND        INELIGIBLE         SANCTIONED             HOUS. CERTIFIED     TYPE: ________________________________

CLIENT’S FIRST NAME	     SERVICE NEED	TASK DESCRIPTION (CLIENT/STAFF RESPONSIBILITY)	SERVICE PROVIDER/AGENCY	START DATE	COMPL. DATE	

SAM	

HOUSING	CL.  - DEVELOP A HOUSING PLAN /REVIEW HOUSING OPTIONS.

(CSW. – REFERRAL TO HOUSING SPECIALIST , ROOM 201 ) 	
MS. JOHNSON, HOUS. SPECIALIST	

1/22/00 		

SAM 	

EMPLOYMENT	CL. – SEEK BANK TELLER POSITION.

(CSW. – ASSIST WITH RESUME, INTERVIEW & JOB SEARCH VIA WKLY. WORKSHOPS.  MEETINGS THURSDAYS AT 2 PM).	
EMPLOYMENT WORKSHOP
CONFERECE ROOM 	

1/27/00 		

TRACY	

SUB. ABUSE	CL. – ENROLL IN ALCOHOL PROGRAM.

(CSW. –  PROVIDE REFERRAL LETTER/FOLLOW-UP)	
BRONX SUB. ABUSE CTR.
345 E. 150 ST.,  BX	

1/31/00		

TRACY	

JOB TRAINING	CL. – ENROLL IN SEED FAMILY DAY CARE.  OPEN ENROLLMENT.

(CSW. –  PROVIDE  REFERRAL LETTER/FOLLOW-UP).	
SEED FAMILY DAY CARE
326 E. 131 ST., BX	

2/10/00 		

MARK               (2)	

CHILD CARE	CL. – ENROLL MARK IN BFR CHILD CARE ON-SITE.

(CSW. – PROVIDE REFERRAL LETTER/FOLLOW-UP).  OPEN ENROLLMENT.	
MS. WINGATE, ROOM 101
BFR CHILD CARE	

1/21/00 	

1/22 	

OTIS                 (7)	

EDUCATION	CL. – WISH TO ENROLL OTIS IN A LOCAL SCHOOL.

(CSW. – REFERRAL TO ON-SITE BD. OF EDUCATION,  ROOM 204).	
MS. HARDING,
BOARD OF EDUCATION	

1/21/00	

1/24	

OTIS	

RECREATION	CL. -  WISH TO ENROLL OTIS IN THE ON-SITE RECREATION PROGRAM.

(CSW. – REFERRAL TO ON-SITE RECREATION , ROOM 203.  OPEN ENROLLMENT.	
MS. JEFFERSON, RECREATION SPECIALIST	

1/21/00 	

1/21 	

OTIS	

MEDICAL	

CL. – WILL CONTINUE OTIS’S MONTHLY BEHAVIORAL MODIFICATION THEARPY.	
DR. ARNOLD JACKSON
15 W. 17 ST., NYC	

1/31/00	

ACTIVE	

MARK	

BENEFITS	

PROVIDE COPY OF BIRTH CERTIFICATE.	

SHIRLEY HAMMER, CSW.	

1/21/00 	

1/25 	
  
                                                                                              TYPES OF SERVICE NEEDS CHECKLIST                                                                                                                                                                                    CHECK DOCUMENTS NEEDED
HOUSING                          	EDUCATION         	 	BENEFITS     		PARENTING SKILLS                      LEGAL SERVICES	DOMESTIC VIOLENCE	Birth Certf. 	      [X]      	Medicaid Card   	
CHILD/REC	JOB TRAINING       	CHILD WELFARE  		UNDOCUMENTED INDIVIDUAL   	SUBSTANCE/ALCOHOL ABUSE  	MENTAL HEALTH                                                      	P.A. Card  		     	S.S Card            	
COUNSELING                 	EMPLOYMENT          	MEDICAL                 	INDEPENDENT LIVING SKILL 	COMMUNITY TIES	OTHER	Medicals    		     	Immunization 	
                                                                                                                                                                                                                                                                                                                                          Passport		     	Food Stamp       	
                                                                                                                                                                             		 	Budget Sheet		Other _________	 
 DATE OF NEXT BI-WEEKLY REVIEW:    FEBRUARY 3,  2000                                                       EXPECTED DURATION OF THA:       FEBRUARY 20,  2001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
I have assisted in the development  and understand the above Service/Independent Living Plan, as required by regulations, as a provision for achieving self-sufficiency and housing.  I further understand that failure to comply with the development and completion of this plan, any Temporary  Assistance or housing requirement as prescribed in 18 NYCRR  Sections 352.35 & 900.10 (c) (1), may result in the discontinuance of my temporary housing.  Attachment A also contains requirements that you must meet.  Please see Attachment A for these additional requirements. 

Client’s Signature:      SAM FOSTER                                      Date:   01/20/00                Caseworker’s Signature:     SHIRLEY HAMMER                               Date:    1/20/00

Other Adult Signature:    TRACY FOSTER                             Date:   01/20/00               Supervisor’s Signature:        PHYSISS JACKSON                              Date:     1/24/00

COMMENTS: _															

																		____	

cc: Original to File
       Copy to Client

SERVICE AND BI-WEEKLY PLAN/INDEPENDENT LIVING PLAN FOR FAMILIES

BRONX FAMILY RESIDENCE
TODAY’S DATE:  02/03/00                                                                                                         (FACILITY NAME) 

CLIENT NAME:       SAM  FOSTER               APT #   2H        INITIAL SERVICE /INDEPENDENT LIVING PLAN   [ ]         BI-WEEKLY REVIEW  [X]   DATE OF ADMISSION:      JANUARY 19, 2000

OTHER ADULT:       TRACY  FOSTER              FAMILY COMP: [2] /[2]             PA/HRA#  101010101010               S.S.#   000-00-0000                    OTHER# _____________________________

P.A. STATUS:  OPEN  [X]     CLOSED        PEND        INELIGIBLE         SANCTIONED             HOUS. CERTIFIED     TYPE: ________________________________

CLIENT’S FIRST NAME	     SERVICE NEED	TASK DESCRIPTION (CLIENT/STAFF RESPONSIBILITY)	SERVICE PROVIDER/AGENCY	START DATE	COMPL. DATE	

SAM	

HOUSING	
CL.  – MEET REALTY BROKER , SEE AL (718) 555-1212/MAINTAIN WEEKLY               HOUSING SEARCH LIST.
          SEE MS. JOHNSON,  HOUSING SPECIALIST , ROOM 201 ON  WED.  2/15).
	
BRONX REALTY
231 E. 149 ST., BX	

2/10/00 	

ACTIVE	

SAM 	

EMPLOYMENT	CL. – SEEK BANK TELLER POSITION.  COMPLETE APPLICATION/SET INTERVIEW.
          CLIENT WILL CONTINUE WEEKLY EMPLOYMENT WORKSHOPS.

(CSW. – ASSIST WITH RESUME, INTERVIEW & JOB SEARCH VIA WKLY. WORKSHOPS.  MEETINGS THURSDAYS AT 2 PM CONFERENCE ROOM).	
BANK OF NEW YORK
116E. 96 ST., NYC	

2/08/00 	

ACTIVE	

TRACY	

SUB. ABUSE	CL. – ENROLLED 2/8.  WILL START WEEKLY THEARPY SESSIONS 2/14.

(CSW. –  WILL FOLLOW-UP)	
BRONX SUB. ABUSE CTR.
345 E. 150 ST.,  BX	

2/14/00 	

ACTIVE	

TRACY	

JOB TRAINING	CL. – ENROLLED IN SEED FAMILY DAY CARE 2/9.  WILL START 2/21 WEEKLY AT 9 AM, MONDAYS AND WEDNESDAYS.

(CSW. –  WILL FOLLOW-UP).	
SEED FAMILY DAY CARE
326 E. 131 ST., BX	

2/21/00 	

ACTIVE	

SAM	
JOB TRAINING
	
CL. - SEEK COMPUTER TRAINING SKILLS, EVENINGS.

(CSW. – PROVIDED LETTER OF REFERRAL).	
BRONX TECHNICAL INST.
349 E. 149 ST., BX	

2/14/00 		

OTIS                (7)

MEDICAL	

WILL CONTINUE BEHAVIORAL THERAPY SESSION.  NEXT SESSION 2/29.	
DR. ARNOLD JACKSON
15 W. 17TH ST., NYC

2/29/00 	

ACTIVE	

						
  
                                                                                              TYPES OF SERVICE NEEDS CHECKLIST                                                                                                                                                                                    CHECK DOCUMENTS NEEDED
HOUSING                          	EDUCATION         	 	BENEFITS     		PARENTING SKILLS                      LEGAL SERVICES	DOMESTIC VIOLENCE	Birth Certf. 	      [ ]      	Medicaid Card   	
CHILD/REC	JOB TRAINING       	CHILD WELFARE  		UNDOCUMENTED INDIVIDUAL   	SUBSTANCE/ALCOHOL ABUSE  	MENTAL HEALTH                                                      	P.A. Card  		     	S.S Card            	
COUNSELING                 	EMPLOYMENT          	MEDICAL                 	INDEPENDENT LIVING SKILL 	COMMUNITY TIES	OTHER	Medicals    		     	Immunization 	
                                                                                                                                                                                                                                                                                                                                          Passport		     	Food Stamp       	
                                                                                                                                                                             		 	Budget Sheet		Other _________	 
 DATE OF NEXT BI-WEEKLY REVIEW:    FEBRUARY  17,  2000                                                       EXPECTED DURATION OF THA:       FEBRUARY 20,  2001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
I have assisted in the development  and understand the above Service/Independent Living Plan, as required by regulations, as a provision for achieving self-sufficiency and housing.  I further understand that failure to comply with the development and completion of this plan, any Temporary  Assistance or housing requirement as prescribed in 18 NYCRR  Sections 352.35 & 900.10 (c) (1), may result in the discontinuance of my temporary housing.  Attachment A also contains requirements that you must meet.  Please see Attachment A for these additional requirements. 

Client’s Signature:      SAM FOSTER                                      Date:   02/03/00                Caseworker’s Signature:     SHIRLEY HAMMER                               Date:    02/03/00

Other Adult Signature:    TRACY FOSTER                             Date:   02/03/00               Supervisor’s Signature:        PHYSISS JACKSON                              Date:     02/04/00

COMMENTS:        OTIS IS ENROLLED IN  PS 24  AND ATTENDS THE ON-SITE RECREATION PROGRAM.  A COPY OF MARK’S BIRTH CERTIFICATE IS ON FILE AND HE IS ATTENDING THE ON-SITE CHILD CARE PROGRAM.

																		____	

cc: Original to File
       Copy to Client

SERVICE AND BI-WEEKLY PLAN/INDEPENDENT LIVING PLAN FOR FAMILIES

GUIDING LIGHT FAMILY  RESIDENCE
TODAYS DATE:  01/03/00                                                                                                         (FACILITY NAME) 

CLIENT NAME:       JANINE BROWNE               APT #   3A        INITIAL SERVICE /INDEPENDENT LIVING PLAN   [X]         BI-WEEKLY REVIEW              DATE OF ADMISSION:      DECEMBER  31, 2000

OTHER ADULT:                                                    FAMILY COMP:    [1] /[4]             PA/HRA#  101010101010               S.S.#   000-00-0000                    OTHER# _____________________________

P.A. STATUS:  OPEN  [X]     CLOSED        PEND        INELIGIBLE         SANCTIONED             HOUS. CERTIFIED     TYPE: ________________________________

CLIENT’S FIRST NAME	     SERVICE NEED	TASK DESCRIPTION (CLIENT/STAFF RESPONSIBILITY)	SERVICE PROVIDER/AGENCY	      START DATE	COMPL. DATE	

JANINE	
DOMESTIC VIOLENCE	
CL.  – WILL PROVIDE CSW. WITH COPY “ORDER OF PROTECTION” by 1/07/00.	

BARBARA THOMAS, CSW.	

 	

JANINE 	

COUNSELING	CL. – WILL MEET WITH MS. C. BANKS, DOMESTIC VIOLENCE COUNSELOR (718) 555-1212   by 1/11/00. 

(CSW. – PROVIDED CLIENT WITH LETTER OF REFERRAL/FOLLOW-UP.	
FOUNDLING FAMILIY CTR.
28 BEACH AVE. BKLYN. 	

JANINE	

MEDICAL	CL. – WILL SEEK MEDICAL ATTENTION FOR HIGH BLOOD PRESSURE AND CONSTANT HEADACES by 1/04/00.

(CSW. –  PROVIDE REFERRAL LETTER/FOLLOW-UP)	
FOUNDILING FAMILY CTR.
28 BEACH AVE. BKLYN.	

JANINE	
INDEPENDENT
LIVING SKILLS	

CL. – WILL ATTEND ORIENTATION WORKSHOP ON-SITE THURSDAY, 1/03/00 at 1:00PM.

CONFERENCE ROOM	

JANINE	

HOUSING	CL. – REPORT TO MS. JOHNSON, HOUSING SPECIALIST. CL  WILL DEVELOP HOUSING PLAN , ATTEND WORKSHOPS AND REVIEW HOUSING OPTIONS by 1/03/00.
	MS. JOHNSON, HOUSING SPECIALIST, ROOM 202 	

	

TOM                 (3)	
CHILD CARE	
CL. – Will GIVE REFERRAL TO ON SITE CHILD CARE DIRECTOR SO TOM CAN BEGIN BY 1/17/00.
(CSW. PROVIDE REFERRAL LETTER)	
MS. WINGATE, DIRECTOR ON-SITE CHILD CARE	

	

MARY (11)  WILL (8)  SANDRA (9) 	

RECREATION	CL. -   TO ENROLL MARY, WILL AND SANDRA IN THE ON-SITE RECREATION PROGRAM BY 1/05/00.

(CSW. – REFERRAL TO ON-SITE RECREATION , ROOM 203.  OPEN ENROLLMENT.	
MS. JEFFERSON, RECREATION SPECIALIST		

MARY, WILL AND SANDRA	

EDUCATION	CL. – TO ENROLL MARY, WILL AND SANDRA IN A LOCAL SCHOOL BY 1/04/00.  

(CSW. – REFERRED CLIENT TO ON-SITE BOARD OF EDUCATION, ROOM 201	
MS HARDING
BD. OF EDUCATION	

	
  
                                                                                              TYPES OF SERVICE NEEDS CHECKLIST                                                                                                                                                                                    CHECK DOCUMENTS NEEDED
HOUSING                          	EDUCATION         	 	BENEFITS     		PARENTING SKILLS                      LEGAL SERVICES	DOMESTIC VIOLENCE	Birth Certf. 	      [ ]      	Medicaid Card   	
CHILD/REC	JOB TRAINING       	CHILD WELFARE  		UNDOCUMENTED INDIVIDUAL   	SUBSTANCE/ALCOHOL ABUSE  	MENTAL HEALTH                                                      	P.A. Card  		     	S.S Card            	
COUNSELING                 	EMPLOYMENT          	MEDICAL                 	INDEPENDENT LIVING SKILL 	COMMUNITY TIES	OTHER	Medicals    		     	Immunization 	
                                                                                                                                                                                                                                                                                                                                          Passport		     	Food Stamp       	
                                                                                                                                                                             		 	Budget Sheet		Other _________	 
 DATE OF NEXT BI-WEEKLY REVIEW:    JANUARY 17,  2000                                                       EXPECTED DURATION OF THA:       SEPTEMBER 10,  2001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
I have assisted in the development  and understand the above Service/Independent Living Plan, as required by regulations, as a provision for achieving self-sufficiency and housing.  I further understand that failure to comply with the development and completion of this plan, any Temporary  Assistance or housing requirement as prescribed in 18 NYCRR  Sections 352.35 & 900.10 (c) (1), may result in the discontinuance of my temporary housing.  Attachment A also contains requirements that you must meet.  Please see Attachment A for these additional requirements. 

Client’s Signature:      JANINE BROWN                                      Date:   01/03/00                Caseworker’s Signature:     BARBARA THOMAS, CSW.                              Date:    1/03/00

Other Adult Signature:                                                                Date:                                    Supervisor’s Signature:        SANDRA WILSON                                           Date:     1/06/00

COMMENTS:																	____	

cc: Original to File
       Copy to Client

SERVICE AND BI-WEEKLY PLAN/INDEPENDENT LIVING PLAN FOR FAMILIES

GUIDING LIGHT FAMILY  RESIDENCE
TODAYS DATE:  01/17/00                                                                                                         (FACILITY NAME) 

CLIENT NAME:       JANINE BROWNE               APT #   3A        INITIAL SERVICE /INDEPENDENT LIVING PLAN   [ ]         BI-WEEKLY REVIEW  [X]            DATE OF ADMISSION:      DECEMBER  31, 2000

OTHER ADULT:                                                    FAMILY COMP:    [1] /[4]             PA/HRA#  101010101010               S.S.#   000-00-0000                    OTHER# _____________________________

P.A. STATUS:  OPEN  [X]     CLOSED        PEND        INELIGIBLE         SANCTIONED             HOUS. CERTIFIED     TYPE: ________________________________

CLIENT’S FIRST NAME	     SERVICE NEED	TASK DESCRIPTION (CLIENT/STAFF RESPONSIBILITY)	SERVICE PROVIDER/AGENCY	START DATE	COMPL. DATE	

JANINE 	

COUNSELING	CL. – WILL CONTINUE WEEEKLY COUNSELING WITH MS. C. BANKS, DOMESTIC VIOLENCE COUNSELOR (718) 555-1212.

(CSW. – PROVIDED CLIENT WITH LETTER OF REFERRAL/FOLLOW-UP.	
FOUNDLING FAMILIY CTR.
28 BEACH AVE. BKLYN. 	

1/11/00	

JANINE	

MEDICAL	CL. – WILL CONTINUE TREATMENT FOR HIGH BLOOD PRESSURE.

(CSW. –  PROVIDE REFERRAL LETTER/FOLLOW-UP)	
FOUNDILING FAMILY CTR.
28 BEACH AVE. BKLYN.	

1/11/00 	

JANINE	
INDEPENDENT
LIVING SKILLS	
CL. – WILL ATTEND BUDGET WORSHOP ON-SITE BY 1/24/00. 
(CSW. WILL FOLLOW UP THAT CLIENT ATTENDED)	

CONFERENCE ROOM	

JANINE	
HOUSING	
CL. – WILL ATTEND HOUSING SEARCH WORKSHOP AND CONTINUE FOLLOW-UP MEETINGS WITH MS. JOHNSON BY 1/31/00. 	
 CONFERENCE ROOM AND MS. JOHNSONS’S OFFICE, ROOM 202.	

	

TOM                 (3)	
CHILD CARE	CL. –WILL CONTACT OTHER CHILD CARE PROVIDERS FOR CARE SINCE NO AVAILABLE SLOTS ON SITE BY 1/31/00. 

(CSW. - WILL PROVIDE LIST OF FAMILY PROVIDERS TO CLIENT).	
RESOURCE LIST OF PROVIDERS.	

	
MARY(11) WILL(8) SANDRA (9) 
	
EDUCATION	CL. WILL ESCORT CHILDREN TO SCHOOL DAILY. 

	PS.123, 134TH AND BRROKLYN AVE. 
	
1/05/00	
	
MARY(11) WILL(8) SANDRA (9) 

	RECREATION 	CL. WILL ENSURE THAT CHILDREN ATTEND RECREATION PROGRAM DAILY.	MS. JEFFERSON , REREATION SPCIALIST	1/05/00		

                                                                                              TYPES OF SERVICE NEEDS CHECKLIST                                                                                                                                                                                    CHECK DOCUMENTS NEEDED
HOUSING                          	EDUCATION         	 	BENEFITS     		PARENTING SKILLS                      LEGAL SERVICES	DOMESTIC VIOLENCE	Birth Certf. 	      [ ]      	Medicaid Card   	
CHILD/REC	JOB TRAINING       	CHILD WELFARE  		UNDOCUMENTED INDIVIDUAL   	SUBSTANCE/ALCOHOL ABUSE  	MENTAL HEALTH                                                      	P.A. Card  		     	S.S Card            	
COUNSELING                 	EMPLOYMENT          	MEDICAL                 	INDEPENDENT LIVING SKILL 	COMMUNITY TIES	OTHER	Medicals    		     	Immunization 	
                                                                                                                                                                                                                                                                                                                                          Passport		     	Food Stamp       	
                                                                                                                                                                             		 	Budget Sheet		Other _________	 
 DATE OF NEXT BI-WEEKLY REVIEW:    FEBRUARY 1,  2000                                                       EXPECTED DURATION OF THA:       SEPTEMBER 10,  2001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
I have assisted in the development  and understand the above Service/Independent Living Plan, as required by regulations, as a provision for achieving self-sufficiency and housing.  I further understand that failure to comply with the development and completion of this plan, any Temporary  Assistance or housing requirement as prescribed in 18 NYCRR  Sections 352.35 & 900.10 (c) (1), may result in the discontinuance of my temporary housing.  Attachment A also contains requirements that you must meet.  Please see Attachment A for these additional requirements. 

Client’s Signature:      JANINE BROWN                                      Date:   01/17/00                Caseworker’s Signature:     BARBARA THOMAS, CSW.                              Date:    1/17/00

Other Adult Signature:                                                                Date:                                    Supervisor’s Signature:        SANDRA WILSON                                           Date:     1/18/00

COMMENTS:  CLIENT SUBMITTED COPY OF “ORDER OF PROTECTION 1/10.  MARY, SANDRA AND WILL ARE ATTENDING PS 49 AND ATTEND THE ON-SITE RECREATION PROGRAM AS OF 1/5.
cc: Original to File
       Copy to Client