Single Coordinated Care Plan
Client Name:

Recovery Support Coordinator:

Eligibility Date:

Initial SCCP Date:

SCCP Revision Date:

Client Vision:

Strengths of Client:

Client Needs	Strengths/Strategies to Meet Needs (Supported by the Strengths Above)
Strengths:

Strategy:

Hr/week	Who	Where	When	Funding Source	Progress/

Accomplished?	Date

Strengths:

Strategy:

Hr/week	Who	Where	When	Funding Source	Progress/

Accomplished?	Date

Client Needs	Strengths/Strategies to Meet Needs (Supported by Strengths Above)
Strengths:

Strategy:

Hr/week	Who	Where	When	Funding Source	Progress/

Accomplished?	Date

Strengths:

Strategy:

Hr/week	Who	Where	When	Funding Source	Progress/

Accomplished?	Date

Strengths:

Strategy:

Hr/week	Who	Where	When	Funding Source	Progress/

Accomplished?	Date

Client Needs	Strengths/Strategies to Meet Needs (Supported by the Strengths Above)

Strengths:

Strategy:

Hr/week	Who	Where	When	Funding Source	Progress/

Accomplished?	Date

Strengths:

Strategy:

Hr/week	Who	Where	When	Funding Source	Progress/

Accomplished?	Date

Strengths:

Strategy:

Hr/week	Who	Where	When	Funding Source	Progress/

Accomplished?	Date

Client Needs	Strengths/Strategies to Meet Needs (Supported by the Strengths Above)
Strengths:

Strategy:

Hr/week	Who	Where	When	Funding Source	Progress/

Accomplished?	Date

Strengths:

Strategy:

Hr/week	Who	Where	When	Funding Source	Progress/

Accomplished?	Date

Notes (Please indicate date of entry):

Follow-up Meeting Date:

Signature of Client:

Date:
Signature of RSC:
Date:
RSC Phone:
Signatures of Team Members
Signature	Date

Informal or

Formal Support	Organization or Relationship with Client	Phone	Invited	Attended

Prohibition on Redisclosure: This notice accompanies a disclosure of information concerning a client in alcohol/drug abuse treatment, made to you with the consent of such client. This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Par 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

Client:	Page 4

Client Vision:

DOMAINS TO CONSIDER
Work and Education	Social Participation/Interpersonal Relationships	Family	Legal	Physical Environment	Housing
Mental/Emotional Health	Leisure Time Activity	Physical/Medical Health	Safety	Community Contacts

DOMAINS TO CONSIDER
Work and Education	Social Participation/Interpersonal Relationships	Family	Legal	Physical Environment	Housing
Mental/Emotional Health	Leisure Time Activity	Physical/Medical Health	Safety	Community Contacts
Research Tracking Code:

Client:	Page 5

Single Coordinated Care Plan

TMG

2005-09-30

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