KCC Behavioral Health Person Centered Plan
 
                                                                                                      Initial        Revision      
     Date of Plan:      
Customer Name:      	S.S.#:      	
1.	Customer’s Desired Goal (customer quote):
            Priority No.      	
 Start Date:       /     /         	
Objectives (Steps to reach goal)	Interventions (include steps of how objectives can be achieved and each service involved)	#Contacts and How Often	Resp Person	Expected date when objective achieved	
     

	     	     	     	     	
     	     
	     	     	     	
2.	Customer’s Desired Goal (customer quote):
               Priority No.      	
 Start Date:        /     /          	
Objectives (Steps to reach goal)	Interventions (include steps of how objectives can be achieved and each service involved)	#Contacts and How Often	Resp Person	Expected date when objective achieved	
     

	     	     	     	     	
     

	     	     	     	     	
3.	Customer’s Desired Goal (customer quote):
              Priority No.      	
 Start Date:       /     /          	
Objectives (Steps to reach goal)	Interventions (include steps of how objectives can be achieved and the service provided)	#Contacts and How Often	Resp Person	Expected date when objective achieved	
     	     	     	     	     	
     	     	     	     	     	
4.	Customer’s Desired Goal (customer quote):
             Priority No.      	
 Start Date:        /     /         	
Objectives (Steps to reach goal)	Interventions (include steps of how objectives can be achieved and the service provided)	#Contacts and How Often	Resp Person	Expected date when objective achieved	
     	     	     	     	     	
     	     	     	     	     	
Areas of concern that will be deferred, or referred to another service agency:	
     	
How the identified health & safety issues are or will be addressed:	
     	
The following are health and safety risks that the consumer chooses to engage in:
     

Risks associated with this choice(s) have been explained.  	
Natural Supports:
Name of Natural Support Provider/Group	
Nature of Natural Supports Being Provided	

     	
     	

     	
     	

     	
     	

     	
     	

Areas in which Natural Supports have been requested	
Plans to attain (build/recruit) Natural Supports with the Customer	

     	
     	

     	
     	

     	
     	

     	
     	

Initial Discharge/Transition Plan:	
     	

Next formal review of treatment plan is in       months or       sessions.	

       Start Time      	Stop Time      
       Billing Code:       
Copies To:   Customer    Guardian          Contract Provider          Other      
Tp\pcp-06126 7/31/02	

Customer’s Signature			Date			Clinician’s Signature			Date
PCP Continuation Page
(To be used when more space is necessary)

Customer Name:      	S.S.#:      	
5.	Goal # that is being continued:                                                                               	
Objectives (Steps to reach goal)	Interventions (include steps of how objectives can be achieved and each service involved)	#Contacts and How Often	Resp Person	Expected date when objective achieved