Form CFS1452-2 "Clinical Intervention for Placement Preservation (Cipp) Action Plan" - Illinois

What Is Form CFS1452-2?

This is a legal form that was released by the Illinois Department of Children and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2013;
  • The latest edition provided by the Illinois Department of Children and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CFS1452-2 by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

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Download Form CFS1452-2 "Clinical Intervention for Placement Preservation (Cipp) Action Plan" - Illinois

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CFS 1452-2
Rev 5/2013
State of Illinois
Department of Children and Family Services
CLINICAL INTERVENTION FOR PLACEMENT PRESERVATION (CIPP)
Action Plan
Identifying Information
Youth name:
ID#:
DOB:
CIPP meeting date:
Meeting date location:
Worker name:
Supervisor name:
Worker phone:
Supervisor phone:
Agency:
Name of person completing the action plan:
Concerns/Needs
1.
Current Priority
Future Priority
2.
Current Priority
Future Priority
3.
Current Priority
Future Priority
4.
Current Priority
Future Priority
5.
Current Priority
Future Priority
6.
Current Priority
Future Priority
7.
Current Priority
Future Priority
8.
Current Priority
Future Priority
9.
Current Priority
Future Priority
10.
Current Priority
Future Priority
Page 1 of 6
CFS 1452-2
Rev 5/2013
State of Illinois
Department of Children and Family Services
CLINICAL INTERVENTION FOR PLACEMENT PRESERVATION (CIPP)
Action Plan
Identifying Information
Youth name:
ID#:
DOB:
CIPP meeting date:
Meeting date location:
Worker name:
Supervisor name:
Worker phone:
Supervisor phone:
Agency:
Name of person completing the action plan:
Concerns/Needs
1.
Current Priority
Future Priority
2.
Current Priority
Future Priority
3.
Current Priority
Future Priority
4.
Current Priority
Future Priority
5.
Current Priority
Future Priority
6.
Current Priority
Future Priority
7.
Current Priority
Future Priority
8.
Current Priority
Future Priority
9.
Current Priority
Future Priority
10.
Current Priority
Future Priority
Page 1 of 6
Youth Name:
ID#:
Page #:
Action Plan
Concern(s) addressed: #_____;
#_____;
#_____;
#_____;
Description of service/support/relationship needed. How, when, where and to whom will it be provided?
Type?
Social/Concrete/Case Management Support
Clinical
Care Environment
Urgency?
Now
Within a Week
Within a Month Who is responsible?
Special approval/supplemental funding assistance?
Yes
No
Concern(s) addressed: #_____;
#_____;
#_____;
#_____;
Description of service/support/relationship needed. How, when, where and to whom will it be provided?
Type?
Social/Concrete/Case Management Support
Clinical
Care Environment
Urgency?
Now
Within a Week
Within a Month Who is responsible?
Special approval/supplemental funding assistance?
Yes
No
Concern(s) addressed: #_____;
#_____;
#_____;
#_____;
Description of service/support/relationship needed. How, when, where and to whom will it be provided?
Type?
Social/Concrete/Case Management Support
Clinical
Care Environment
Urgency?
Now
Within a Week
Within a Month Who is responsible?
Special approval/supplemental funding assistance?
Yes
No
Page 2 of 6
Youth Name:
ID#:
Page #:
Action Plan Continued
Concern(s) addressed: #_____;
#_____;
#_____;
#_____;
Description of service/support/relationship needed. How, when, where and to whom will it be provided?
Type?
Social/Concrete/Management Support
Clinical
Care Environment
Urgency?
Now
Within a Week
Within a Month
Who is responsible?
Special approval/supplemental funding assistance?
Yes
No
Concern(s) addressed: #_____;
#_____;
#_____;
#_____;
Description of service/support/relationship needed. How, when, where and to whom will it be provided?
Type?
Social/Concrete/Management Support
Clinical
Care Environment
Urgency?
Now
Within a Week
Within a Month
Who is responsible?
Special approval/supplemental funding assistance?
Yes
No
Concern(s) addressed: #_____;
#_____;
#_____;
#_____;
Description of service/support/relationship needed. How, when, where and to whom will it be provided?
Type?
Social/Concrete/Case Management Support
Clinical
Care Environment
Urgency?
Now
Within a Week
Within a Month
Who is responsible?
Special approval/supplemental funding assistance?
Yes
No
Page 3 of 6
Youth Name:
ID#:
Page #:
Action Plan Continued
Concern(s) addressed: #_____;
#_____;
#_____;
#_____;
Description of service/support/relationship needed. How, when, where and to whom will it be provided?
Type?
Social/Concrete/Management Support
Clinical
Care Environment
Urgency?
Now
Within a Week
Within a Month
Who is responsible?
Special approval/supplemental funding assistance?
Yes
No
Concern(s) addressed: #_____;
#_____;
#_____;
#_____;
Description of service/support/relationship needed. How, when, where and to whom will it be provided?
Type?
Social/Concrete/Management Support
Clinical
Care Environment
Urgency?
Now
Within a Week
Within a Month
Who is responsible?
Special approval/supplemental funding assistance?
Yes
No
Concern(s) addressed: #_____;
#_____;
#_____;
#_____;
Description of service/support/relationship needed. How, when, where and to whom will it be provided?
Type?
Social/Concrete/Case Management Support
Clinical
Care Environment
Urgency?
Now
Within a Week
Within a Month
Who is responsible?
Special approval/supplemental funding assistance?
Yes
No
Page 4 of 6
Youth Name:
ID#:
Page #:
Proactive Stability and Crisis Plan
Situations that could lead to a crisis:
Youth’s strategies for managing conflict/crisis:
Caregiver’s strategies for managing conflict/crisis:
Supports and resources including names and contact information of people who will help:
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