Form CFS968-62C "Ilo/Tlp Wraparound Plan" - Illinois

What Is Form CFS968-62C?

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, 2001;
  • 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 CFS968-62C 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 CFS968-62C "Ilo/Tlp Wraparound Plan" - Illinois

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CFS 968-62C
State of Illinois
Department of Children and Family Services
Rev. 05/01
ILO/TLP WRAPAROUND PLAN
A. DEMOGRAPHICS
1. Child Name:
2. Date of Birth:
3. Age:
4. Gender:
5. DCFS Child ID#:
6. DCFS Family ID#:
7. Child's Current Address:
City:
State:
Zip:
8.Child’s Current Living Arrangement:
HMR
Regular Foster Care
Specialized or Treatment Foster Care
Residential Care
Detention
Department of Corrections Facility
Emergency Shelter
Hospitalized
Other (Specify)
9. Permanency Goal:
10. LAN of Relevance:
11. WSAA:
12. DCFS Region:
13. Clinical Convener:
Phone:
14. Case Worker:
Phone:
15. Supervisor:
Phone:
This plan must be completed for any youth who is being recommended for either independent living services or transitional living
program services per the provisions of Policy Guide 2001.10. The plan must be submitted to the appropriate regional Clinical
Services Manager with all other information that is required by Policy Guide 2001.10 (see Policy Guide 2001.10, Appendix A).
The plan should describe in detail the services and interventions that would be provided to the youth should the youth be
approved for independent living services or transitional living services by the appropriate regional Clinical Services Manager and
the Deputy Director of the Division of Education and Transition Services.
Additionally, a CFS 968-62B, ILO, Safety and Risk Management Plan, MUST be completed and attached to this form for any
youth who has one or more of the following conditions or problems as listed in Policy Guide 2001.10: mental illness/mental
health problem; sexually aggressive child or youth; developmental disability; delinquency; Department of Corrections; alcohol or
drug abuse; physically aggressive; gang involvement; and/or complex/serious medical problem.
B. LIFE DOMAINS
1. PHYSICAL NEEDS/LIVING SITUATION - Describe the living arrangement of the child and the basic and financial needs
Clothing,
of the youth. Key Issues: Space, Privacy, Safety, Adult Supervision, Comfort, Local Resources, Food,
Furnishings
and Transportation
a. Identify the services, goods, supports, and other interventions requested for this domain and the measurable changes,
which are desired or anticipated which support the child and family, and respond to the stated needs.
b. At this time the youth does not have any needs in this area. Initials
and Date:
- 1
Page
CFS 968-62C
State of Illinois
Department of Children and Family Services
Rev. 05/01
ILO/TLP WRAPAROUND PLAN
A. DEMOGRAPHICS
1. Child Name:
2. Date of Birth:
3. Age:
4. Gender:
5. DCFS Child ID#:
6. DCFS Family ID#:
7. Child's Current Address:
City:
State:
Zip:
8.Child’s Current Living Arrangement:
HMR
Regular Foster Care
Specialized or Treatment Foster Care
Residential Care
Detention
Department of Corrections Facility
Emergency Shelter
Hospitalized
Other (Specify)
9. Permanency Goal:
10. LAN of Relevance:
11. WSAA:
12. DCFS Region:
13. Clinical Convener:
Phone:
14. Case Worker:
Phone:
15. Supervisor:
Phone:
This plan must be completed for any youth who is being recommended for either independent living services or transitional living
program services per the provisions of Policy Guide 2001.10. The plan must be submitted to the appropriate regional Clinical
Services Manager with all other information that is required by Policy Guide 2001.10 (see Policy Guide 2001.10, Appendix A).
The plan should describe in detail the services and interventions that would be provided to the youth should the youth be
approved for independent living services or transitional living services by the appropriate regional Clinical Services Manager and
the Deputy Director of the Division of Education and Transition Services.
Additionally, a CFS 968-62B, ILO, Safety and Risk Management Plan, MUST be completed and attached to this form for any
youth who has one or more of the following conditions or problems as listed in Policy Guide 2001.10: mental illness/mental
health problem; sexually aggressive child or youth; developmental disability; delinquency; Department of Corrections; alcohol or
drug abuse; physically aggressive; gang involvement; and/or complex/serious medical problem.
B. LIFE DOMAINS
1. PHYSICAL NEEDS/LIVING SITUATION - Describe the living arrangement of the child and the basic and financial needs
Clothing,
of the youth. Key Issues: Space, Privacy, Safety, Adult Supervision, Comfort, Local Resources, Food,
Furnishings
and Transportation
a. Identify the services, goods, supports, and other interventions requested for this domain and the measurable changes,
which are desired or anticipated which support the child and family, and respond to the stated needs.
b. At this time the youth does not have any needs in this area. Initials
and Date:
- 1
Page
CFS 968-62C
State of Illinois
Department of Children and Family Services
Rev. 05/01
2. FAMILY/ATTACHMENT - Describe the child's current or planned family arrangement - Key Issues: Family Constellation,
Extended Family, Family Relationships, Mentoring, Significant Others, Relationship with Siblings, Permanency
a. Does the youth have regular contact with and support from family, extended family, and significant others? What
services, supports and other interventions are needed to support the youth’s connectedness and support for transition
to adulthood?_________________________________________________________________________________
b. At this time the youth does not have any needs in this area. Initials
and Date:
3. SAFETY/RISK - Describe the youth’s current or planned situation in terms of crisis management/ability to handle crisis or
emergency situations. Key Issues: Emergency Contacts/Resources, Potential Precipitators, Strategy and Resolution, Crisis
Management
a. Does the youth have a history of one or more of the following conditions or problems as listed in Policy Guide
2001.10..: mental illness/mental health problem; sexually aggressive child or youth; developmental disability;
delinquency; Department of Corrections; alcohol or other drug abuse; physically aggressive; gang involvement;
and/or complex/serious medical condition? ____ Yes ___ No
b. If YES, complete and attach the Safety and Risk Management Plan (CFS 968-62B) Possible services include:
additional casework support, protective services, SACY plan, day treatment, informal community supports,
professional services, relapse prevention services.
At this time the youth does not have any needs in this area. Initials
and Date:
4. SOCIALIZATION - Describe the youth’s/family's current or planned social and recreational patterns. Key Issues: Physical
Fitness, Hobbies/Interests, Support Systems, Friends, Family Bonds
a. Does youth have friends and extra-curricular activities? Identify the services that may be needed to support the
youth’s integration into the community and the development of self-esteem and positive bonds.
______
b. At this time the youth does not have any needs in this area. Initials
and Date:
5. CULTURAL AND SPIRITUAL - Describe any ethnic, national, spiritual traditions and interests important to the
youth/family. Key Issues: traditions, mores, faith, beliefs, language, support, comfort
a. Identify key services that the youth needs to support any cultural or spiritual traditions that the youth has or may
aspire to have.________________________________________________________________________________
b. At this time the youth does not have any needs in this area. Initials
and Date:
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Page
CFS 968-62C
State of Illinois
Department of Children and Family Services
Rev. 05/01
6. EMOTIONAL/PSYCHOLOGICAL - Discuss the significant mental health and/or behavior management issues involving
the youth, including psychological, psychiatric or substance abuse matters. Key Issues: family history, current behavioral
status, current psychological status, alcohol/drug abuse history and psychotropic medications
a. Identify the services, supports and other interventions necessary to meet the youth’s mental health needs and the
changes that are desired or anticipated in the youth’s emotional well-being.
b. At this time the youth does not have any needs in this area. Initials
and Date:
7. HEALTH - Discuss the physical and dental history and health status of the youth. Key Issues: Medication(s), Special
Needs(s), Access to Medical/Dental Care, Immunizations, Well-Baby Care, Pregnancy and STD Prevention
a.
Identify the services, supports, and other interventions necessary to support the youth in securing regular and
extraordinary preventive and interventive health care._________________________________________________
b. At this time the youth does not have any needs in this area. Initials
and Date:
8. EDUCATIONAL/VOCATIONAL - Describe current or desired educational status and, if applicable, work experience.
Key Issues: Grade Level, Specialized Educational Support, Work Experience, Goals/Interests, Vocational Education,
Youth in College and Youth in Scholarship program, literacy, post emancipation support
a. Identify the services, supports and interventions necessary for any youth, who has not completed high school or not
attained GED. If the youth plans to attend college, identify supports needed for the educational plan.
b. At this time the youth does not have any needs in this area. Initials
and Date:
c.
The youth received his/her high school diploma/GED on Date: __________
9.
PREGNANT AND PARENTING TEENS - Describe, discuss and identify the parenting ward’s (male or female) current
needs in the areas of parenting education, child care /child care transportation; infant medical services; housing especially
for parents with 3 or more children; etc per Appendix J, Rule and Procedure 302.
a. Identify the parenting/pregnant ward’s needs to successfully complete the pregnancy and/or to effectively raise and
care for her/his children, keeping in mind any special services needed due to issues raised in sections 6 & 7.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
b. At this time the youth does not have any needs in this area. Initials _________________and Date: ____________
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Page
CFS 968-62C
State of Illinois
Department of Children and Family Services
Rev. 05/01
10. LEGAL - Describe history of involvement with law enforcement and/or the courts. Key Issues: Current Legal Status,
DCFS Status, DOC, Adjudication, Probation, Parole
Identify the services, supports, and other interventions requested for this domain and the measurable changes, which
a.
are desired or anticipated.
At this time the youth does not have any needs in this area. Initials
and Date:
b.
C. WRAPAROUND PLAN BUDGET
(6)
(1)
(2)
(3)
(4)
(5)
(7)
(8)
WRAP
Life Domains
Services/Goods/
Unit
Frequency
WSAA
Other Funds and
Wrap Total
Exception
(Identify the life
Funds
(Column 5
Interventions
Rate
Source of Other
Needed?
domain for each
Plus Column
Funds
service/good/inter-
= Total)
7a
Intervention in this
a. Funds b. source
Plan)
Yes
No
TOTALS
$
$
$
NOTE: EXCEPTION APPROVAL PROCESS FOR DCFS WRAPAROUND PLANS
As stated in the preface to the Wraparound Service and Rate Catalog, any funds requested from the WSAA
that are an exception to goods or services listed in the catalog must be authorized by the Associate Deputy
Director and the signed exception must be attached to the Wraparound Plan BEFORE obtaining approval at
the appropriate level(s) as designated below. These exceptions should also be noted in Column 6 of “Section
F. Wraparound Plan Budget” on Page 6 of this Wraparound Plan.
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Page
CFS 968-62C
State of Illinois
Department of Children and Family Services
Rev. 05/01
APPROVAL/SIGNOFF
D.
1. Supervisor:
Date:
2. Field Service Manager
Date:
or Clinical Service Coordinator
3. Recommended ILO-TLP Provider:
Date
4. Regional Clinical Manager:
Date:
5. DCFS Regional Administrator: ________________________________
Date: _______________________________
(Required ONLY for youth previously denied by DETS)
6. Deputy Director:
Date:
Division of Education and Transition Services
Wraparound Plan Start Date:
Wraparound Plan End Date:
DCFS staff approval is needed and Wraparound Plan will be processed through the appropriate
Wraparound System Administrative Agent (WSAA).
a.
For plans of $4,000 or less and up to four months in duration:
Clinical Convener:
Date:
b. For plans between $4,000 - $18,000 and/or between four to six months in duration, this level approval is also needed:
Regional Administrator:
Date:
c.
For plans over $18,000 and/or longer than six months in duration, this level approval is also needed:
Deputy Director/Operations:
Date:
NOTE: Services are only authorized for the time period of this Wraparound Plan. Services may NOT begin prior to the approval
date of the highest level of signature required regardless of level of signature needed.
E. CHILD AND FAMILY TEAM MEMBER SIGNATURE SHEET
CORE TEAM MEMBERS
Printed Name
Signature
Date
Family Member:
Child (if over 12):
Caregiver/Current/Prospective:
Wraparound Facilitator:
DCFS/POS Case Worker:
Staffing Convener (FSM or CSC)
ILO-TLP Provider:
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