INDIVIDUAL CARE PLAN

Participant:
Last First MR#
Care Coordinator/Case Manager (if any): ____________________________________________

Date: ________________ Client Present: Yes No If no, why not

Scheduled Days: M T W Th F Special Diet:

Caregiver involved: Yes No If yes, name:

Address: City, State: ______

Relationship to client: Specific Responsibilities:

____________

______

NEED GOAL Approaches to meeting the Responsible Date to be

(short term Goals person accomplished
long term) (Specific Measurable)

Staff Signature: _____________________________________ Date____________

Participant/Representative: ________________________________ Date: _______________

Katie Adult Day Center Policies and Procedures Manual 10-019.16

 Care Plan Review/ Modifications (comment if no change and next review date and initial or
update/revise on next pages):
NEED GOAL Approaches to Responsible Date to be
(short term meeting the Goals person accomplished
long term) (Specific
Measurable)

Sign and date for any updates/revisions/reviews document who is involved in the review:

Katie Adult Day Center Policies and Procedures Manual 10-019.16