Case Management Case Plan Template

CASE MANAGEMENT CASE PLAN

WHEREAS, Provider Name: is a duly authorized case management provider offering assessment, planning, coordination, and supportive services; and

WHEREAS, Client Name: has voluntarily engaged the Provider to develop a written case plan to address identified needs, goals, and services; and

WHEREAS, the parties desire to set forth the scope, responsibilities, confidentiality protections, payment terms (if any), and review procedures for the case management services to be delivered under this Case Plan.

Parties and Primary Contacts

Case Summary / Presenting Issues

Strengths, Risks, and Needs Assessment

Strengths:

Identified Risks and Safety Concerns:

Goals, Objectives, and Tasks

Goal 1 Description

Responsible Party:    Target Date:

Goal 2 Description

Responsible Party:    Target Date:

Scope of Work

The Provider shall perform the following services, to be delivered in accordance with the objectives above. Services include coordination, referral, monitoring, documentation, advocacy, and direct assistance as specified below. The Provider's obligations are limited to the services expressly set forth in this Case Plan unless otherwise agreed in writing.

Services and Referrals

Check services to be provided or arranged:

Housing assistance    Employment services    Education/training

Legal advocacy    Mental health services    Substance use treatment

Other:

Payment Terms

If applicable, Client shall pay Provider as follows. Any fees must be agreed in advance and documented in writing. Failure to pay timely may result in suspension or termination of non-essential services.

Term and Termination

This Case Plan shall commence on Start Date: and shall continue until End Date: unless earlier terminated in accordance with this section.

Either party may terminate this Case Plan for convenience by providing advance written notice to the other party. Notice Period: days. Termination for cause may occur immediately if there is a material breach, danger to safety, or other exigent circumstance.

Confidentiality

All records, notes, assessments, and other information created in the course of providing case management services are confidential and will be used only for purposes of service delivery, planning, and required reporting. Information will not be released to third parties without Client's written consent except where disclosure is required by law, court order, or in situations involving imminent risk of harm or abuse.

Client acknowledges the confidentiality provisions and provides consent to share information with identified collateral service providers for coordination of services: I acknowledge and consent

Review, Monitoring, and Reporting

Progress toward goals will be reviewed at regular intervals. Next review date: . Provider will document progress and furnish summaries to Client or authorized representatives upon request consistent with confidentiality provisions.

Governing Law

This Case Plan shall be governed by and construed in accordance with the laws of the jurisdiction specified below. Governing Jurisdiction:

Entire Agreement

This Case Plan, together with any attachments or addenda signed by the parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, proposals, and communications, whether oral or written. Any amendment must be in writing and signed by both parties.

Client Rights and Responsibilities

Client agrees to participate in planning and reasonable cooperation with services, to notify Provider of changes in circumstances, and to provide accurate information. Client retains the right to decline specific services and to request modification of the Case Plan. Client acknowledges receipt of a copy of this Case Plan upon signing.

Client consents to the terms of this Case Plan: Client consents

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