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Office of Mental Health

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

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 HCBS Waiver Aftercare Follow–Up Plan 

Note: Follow-up with the family after discharge from the Waiver must be individualized with a minimum of two contacts in the first month at week two and week four.  If all linkages are in place, no additional follow-up is necessary.  However, if circumstances warrant, follow-up contacts may be planned for the following month two and three as needed. Additional contacts during the first three months may be necessary depending on circumstances.

Child’s Name:   Discharge Date:  

Two-Week Follow–Up

Date:   Family member contacted:  
Worker making the contact:   Title:  
  1. Has the Discharge Plan been fully implemented?
    Yes ___ No ___
    If no, describe barriers to completion and actions to be taken:

  2. Summarize how the child and family are doing:
  3. Has the Notice Of Decision: Termination form been received and placed in the case folder?
    Yes ___ No ___
    If no, describe barriers to completion and actions to be taken:
Follow Up Completed by:
(name and title)
  Date:  
ICC Supervisor Signature:   Date:  

Four-Week Follow-Up:

Date:   Family member contacted:  
Worker making the contact:   Title:  
  1. Has the Discharge Plan been fully implemented?
    Yes ___ No ___ If no, describe barriers to completion and actions to be taken:
  2. Summarize how the child and family are doing:
  3. Has the Notice Of Decision: Termination form been received and placed in the case folder?
    Yes ___ No ___
    If not, please contact the Operations Support Unit at the Office of Mental Health.
Follow Up Completed by:
(name and title)
  Date:  
ICC Supervisor Signature:   Date:  

Follow–Up Month Two: (as needed)

Date:   Family member contacted:  
Worker making the contact:   Title:  
  1. Has the Discharge Plan been fully implemented?
    Yes ___ No ___ If no, describe barriers to completion and actions to be taken:
  2. Summarize how the child and family are doing:
Follow Up Completed by:
(name and title)
  Date:  
ICC Supervisor Signature:   Date:  

FOLLOW-UP MONTH THREE: (as needed):

Date:   Family member contacted:  
Worker making the contact:   Title:  
  1. Has the Discharge Plan been fully implemented?
    Yes ___ No ___ If no, describe barriers to completion and actions to be taken:
  2. Summarize how the child and family are doing:
Follow Up Completed by:
(name and title)
  Date:  
ICC Supervisor Signature:   Date:  

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.