ࡱ> HK;<=>?@ABCDEFG^@ jbjbj.. .DDF0000((( ~, $*L**,3.08 9p>/$Rt(@23@@00*, kkk@4 0*(,>k@>kk.l (* 6 m7*M*<30ć&OROT 0000O(|9l;bk<=|9|9|9 ek^  INTERAGENCY PLAN Contents Section 1. Identifying information and consent Section 2. Planned interventions Section 3. Funding requests Section 4. Local management sign-off Section 5. Form feedback NAME OF CHILD OR YOUNG PERSON FORMTEXT      Date of birth:  FORMTEXT      Plan number:  FORMTEXT      Including reviews:  FORMCHECKBOX  1  FORMCHECKBOX  2  FORMCHECKBOX  3  FORMCHECKBOX  4 Date of review:  FORMTEXT      Checklist before sending to the HCN UnitPLAN FORMCHECKBOX  Consent has been gained from legal guardians and the child or young person has been informed  FORMCHECKBOX  Reports (listed in document) are attached  FORMCHECKBOX  HCN Advisor has read the plan/review and provided feedback  FORMCHECKBOX  Lead agency identified and plan and funding request signed by Manager  FORMCHECKBOX  Lead agency finance role identified and contact details provided  FORMCHECKBOX  Lead Agency has a contract in place with a Services Coordinator  FORMCHECKBOX  Interagency team contact details are complete  FORMCHECKBOX  Local managers from two different agencies have read and signed the form  FORMCHECKBOX  Specialist advisers identified and contact details provided (if applicable)  FORMCHECKBOX  Arranged to send a signed hard copy and electronic copy to the HCN UnitREVIEWS FORMCHECKBOX  Feedback has been sought from child or young person, family, caregivers, ServicesCoordinatorandinteragencyteam  FORMCHECKBOX  Report of actual expenditure against plan budget included  FORMCHECKBOX  Funding change requests are signed by Lead Agency Manager Please courier or post signed hard copy to: HCN Unit Attention: Administration Support c/- Child Youth and Family Services Bowen State Building 34 Bowen Street P O Box 2620 WELLINGTONAnd send electronic copy to: hcn@cyf.govt.nz enter Plan or Review in the subject line  Section 1: Identifying information and consent IDENTIFYING INFORMATIONChild or young personName First name:  FORMTEXT       Second name(s):  FORMTEXT       Last name:  FORMTEXT      Also known as First name:  FORMTEXT       Second name(s):  FORMTEXT       Last name:  FORMTEXT      Date of birth:  FORMTEXT      Age:  FORMTEXT       yearsGender:  FORMCHECKBOX  Male  FORMCHECKBOX  Female  FORMCHECKBOX  OtherEthnicity (if Mori, indicate iwi affiliations): Ethnicity:  FORMTEXT       Iwi:  FORMTEXT      Current residential address Street address:  FORMTEXT       Postal address:  FORMTEXT      Current school/day time address Street address:  FORMTEXT       Postal address:  FORMTEXT      Parent/s, whnauMother First name:  FORMTEXT       Last name:  FORMTEXT      Mother also known as First name:  FORMTEXT       Last name:  FORMTEXT      Mother s address Street address:  FORMTEXT       Postal address:  FORMTEXT      Father First name:  FORMTEXT       Last name:  FORMTEXT      Father also known as First name:  FORMTEXT       Last name:  FORMTEXT      Father s address Street address:  FORMTEXT       Postal address:  FORMTEXT       Guardian (if different from above)Name First name:  FORMTEXT       Last name:  FORMTEXT      Also known as First name:  FORMTEXT       Last name:  FORMTEXT      Relationship to child:  FORMTEXT      Address Street address:  FORMTEXT       Postal address:  FORMTEXT      Caregivers (including respite caregivers)Name First name:  FORMTEXT       Last name:  FORMTEXT      Also known as First name:  FORMTEXT       Last name:  FORMTEXT      Relationship to child:  FORMTEXT      Address Street address:  FORMTEXT       Postal address:  FORMTEXT       REVIEWS  CHILD/ YOUNG PERSON AND WHNAU/FAMILY FEEDBACKReview 1 View of child or young person Feedback from family/whnau Feedback from caregivers Review 2View of child or young person Feedback from family/whnau Feedback from caregivers Review 3View of child or young person Feedback from family/whnau Feedback from caregivers Review 4View of child or young person Feedback from family/whnau Feedback from caregivers  Information, Privacy and Consent The personal information in this form relates to the history and the needs of the child or young person and is required: To allow the HCN Unit to assess whether the child or young persons plan is likely to meet their needs. To provide information for reviewing the plan by the interagency team supporting the child or young person and by HCN Unit employees. The information collected here will also help in assessing the effectiveness of the High and Complex Needs Interagency Strategy and may be used for research purposes. When used in this way the information will not identify individual children and young people. The personal information collected will be held by: HCN staff in order to make funding approval decision, following which duplicate copies will be destroyed. The HCN Unit hosted by Child, Youth and Family at National Office, Bowen State Building, 34 Bowen Street, Wellington, and its employees for the purposes outlined above. Electronic and paper files will be archived securely by Child, Youth and Family Services, who host the HCN Unit. The child or young person and their parents/guardians have the right to see personal information held and to have any inaccuracies corrected in accordance with the Privacy Act 1993. INFORMATION AND CONSENTChild or young personSomeone has talked to me about this plan.Signature: Date:Name (please print):If not signed please explain how child or young person has been informed:  FORMTEXT      Parent/s, whnau, Guardian/sI agree with and consent to this plan. I understand and agree to the privacy statement.Signature: Date:Name (please print):Signature: Date:Name (please print):Where parental consent is not included, please explain:  FORMTEXT      Caregiver/sI agree with this plan. I understand and agree to the privacy statement.Signature: Date:Name (please print): CHANGES SINCE APPLICATION APPROVALPlease show below any change in the child or young persons status.PLANREVIEW 1REVIEW 2REVIEW 3REVIEW 4DETAILSHave the child or young persons living arrangements changed? FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Has their legal status changed? FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Has the child or young person changed educational placement? FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Have there been any changes to the interagency team or advisors? (If yes, please give details below.) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      Other  give details:  FORMTEXT       FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       INTERAGENCY TEAMThat has contributed to the plan and will continue to support the child or young person throughout and following implementation.Team membersName First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Employer:  FORMTEXT        FORMCHECKBOX  Public  FORMCHECKBOX  Private  FORMCHECKBOX  NGOEmail:  FORMTEXT      Phone:  FORMTEXT      Mobile:  FORMTEXT      Fax:  FORMTEXT      Address Street address:  FORMTEXT       Postal address:  FORMTEXT       SPECIALIST ADVISORS TO INTERAGENCY TEAM HCN AdvisorName:  FORMTEXT      Clinical Advisor/Consultant (if appropriate)Name First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Employer:  FORMTEXT        FORMCHECKBOX  Public  FORMCHECKBOX  Private  FORMCHECKBOX  NGOEmail:  FORMTEXT      Phone:  FORMTEXT      Mobile:  FORMTEXT      Fax:  FORMTEXT      Address Street address:  FORMTEXT       Postal address:  FORMTEXT      Cultural Advisor (if appropriate)Name First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Employer:  FORMTEXT        FORMCHECKBOX  Public  FORMCHECKBOX  Private  FORMCHECKBOX  NGOEmail:  FORMTEXT      Phone:  FORMTEXT      Mobile:  FORMTEXT      Fax:  FORMTEXT      Address Street address:  FORMTEXT       Postal address:  FORMTEXT       LEAD AGENCY CONTACTSServices CoordinatorName First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Employer:  FORMTEXT        FORMCHECKBOX  Public  FORMCHECKBOX  Private  FORMCHECKBOX  NGOEmail:  FORMTEXT      Phone:  FORMTEXT      Mobile:  FORMTEXT      Fax:  FORMTEXT      Address Street address:  FORMTEXT       Postal address:  FORMTEXT      Financial contactName First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Employer:  FORMTEXT        FORMCHECKBOX  Public  FORMCHECKBOX  Private  FORMCHECKBOX  NGOEmail:  FORMTEXT      Phone:  FORMTEXT      Mobile:  FORMTEXT      Fax:  FORMTEXT      Address Street address:  FORMTEXT       Postal address:  FORMTEXT       CONFLICT OF INTERESTPOTENTIAL CONFLICT OF INTERESTHOW THIS WILL BE MANAGED? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       REVIEWS  FEEDBACK FROM THE INTERAGENCY TEAM ON THE INTERAGENCY TEAM PROCESSReview 1 Attendees:Are services in place? Is the HCN Unit being journalled/invoiced for services? Feedback on interagency process Review 2Attendees:Is the HCN Unit being journalled/invoiced for services? Feedback on interagency process Review 3Attendees:What is the intention for next year? Is the HCN Unit being journalled/invoiced for services? Feedback on interagency process Review 4Attendees: Is the HCN Unit being journalled/invoiced for services? Feedback on interagency process  Section 2: Planned interventions LONG-TERM VISION i.e if all goes well, what will the child be doing in 2 to 3 years time?  FORMTEXT       OTHER PLANSPlease list all significant plans currently in place for this child or young personNAME OF PLANDATE OF PLAN EXPIRYIS THIS COMPATIBLE WITH THE HCN PLAN? (Pleaseexplain) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Wellbeing Framework: LIVING ARRANGEMENTSRelevant history / rationale  FORMTEXT      Current situation, including strengths and unmet needs  FORMTEXT      Goals for next twelve months  FORMTEXT      DESCRIPTION OF INTERVENTIONS NEEDED TO MEET THE GOALS (Identify tasks, activities or methods to achieve the goals)SERVICE CONTRIBUTIONHCN FUNDING REQUEST (Y/N) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Outcome measure How will the team measure achievement of goals ?  FORMTEXT       Specify baseline measure(s)  FORMTEXT       REVIEWS  REVIEW OF INTERVENTIONS FOR LIVING ARRANGEMENTSProvide detailsReview 1 What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 2What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 3What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 4What progress has been made towards goals?Have the outcomes been achieved?Please provide report on outcome measures (Attach if a report) Wellbeing Framework: WHNAU/FAMILY RELATIONSHIPSRelevant history / rationale  FORMTEXT      Current situation, including strengths and unmet needs  FORMTEXT      Goals for next twelve months  FORMTEXT      DESCRIPTION OF INTERVENTIONS NEEDED TO MEET THE GOALS (Identify tasks, activities or methods to achieve the goals)SERVICE CONTRIBUTIONHCN FUNDING REQUEST (Y/N) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Outcome measure How will the team measure achievement of goals ?  FORMTEXT       Specify baseline measure(s)  FORMTEXT       REVIEWS  REVIEW OF INTERVENTIONS FOR WHNAU/FAMILY RELATIONSHIPSProvide detailsReview 1 What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 2What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 3What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 4What progress has been made towards goals?Have the outcomes been achieved?Please provide report on outcome measures (Attach if a report) Wellbeing Framework: EDUCATIONAL/VOCATIONAL NEEDSRelevant history / rationale  FORMTEXT      Current situation, including strengths and unmet needs  FORMTEXT      Goals for next twelve months  FORMTEXT      DESCRIPTION OF INTERVENTIONS NEEDED TO MEET THE GOALS (Identify tasks, activities or methods to achieve the goals)SERVICE CONTRIBUTIONHCN FUNDING REQUEST (Y/N) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Outcome measure How will the team measure achievement of goals ?  FORMTEXT       Specify baseline measure(s)  FORMTEXT       REVIEWS  REVIEW OF INTERVENTIONS FOR EDUCATIONAL/VOCATIONAL NEEDSProvide detailsReview 1 What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 2What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 3What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 4What progress has been made towards goals?Have the outcomes been achieved?Please provide report on outcome measures (Attach if a report) Wellbeing Framework: HEALTH AND DISABILITYRelevant history / rationale  FORMTEXT      Current situation, including strengths and unmet needs  FORMTEXT      Goals for next twelve months  FORMTEXT      DESCRIPTION OF INTERVENTIONS NEEDED TO MEET THE GOALS (Identify tasks, activities or methods to achieve the goals)SERVICE CONTRIBUTIONHCN FUNDING REQUEST (Y/N) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Outcome measure How will the team measure achievement of goals ?  FORMTEXT       Specify baseline measure(s)  FORMTEXT       REVIEWS  REVIEW OF INTERVENTIONS FOR HEALTH AND DISABILITYProvide detailsReview 1 What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 2What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 3What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 4What progress has been made towards goals?Have the outcomes been achieved?Please provide report on outcome measures (Attach if a report) Wellbeing Framework: EMOTIONAL WELLBEINGRelevant history / rationale  FORMTEXT      Current situation, including strengths and unmet needs  FORMTEXT      Goals for next twelve months  FORMTEXT      DESCRIPTION OF INTERVENTIONS NEEDED TO MEET THE GOALS (Identify tasks, activities or methods to achieve the goals)SERVICE CONTRIBUTIONHCN FUNDING REQUEST (Y/N) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Outcome measure How will the team measure achievement of goals ?  FORMTEXT       Specify baseline measure(s)  FORMTEXT       REVIEWS  REVIEW OF INTERVENTIONS FOR EMOTIONAL WELLBEINGProvide detailsReview 1 What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 2What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 3What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 4What progress has been made towards goals?Have the outcomes been achieved?Please provide report on outcome measures (Attach if a report) Wellbeing Framework: CULTURAL IDENTITYRelevant history / rationale  FORMTEXT      Current situation, including strengths and unmet needs  FORMTEXT      Goals for next twelve months  FORMTEXT      DESCRIPTION OF INTERVENTIONS NEEDED TO MEET THE GOALS (Identify tasks, activities or methods to achieve the goals)SERVICE CONTRIBUTIONHCN FUNDING REQUEST (Y/N) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Outcome measure How will the team measure achievement of goals ?  FORMTEXT       Specify baseline measure(s)  FORMTEXT       REVIEWS  REVIEW OF INTERVENTIONS FOR CULTURAL IDENTITYProvide detailsReview 1 What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 2What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 3What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 4What progress has been made towards goals?Have the outcomes been achieved?Please provide report on outcome measures (Attach if a report) Wellbeing Framework: LIFE SKILLS DEVELOPMENTRelevant history / rationale  FORMTEXT      Current situation, including strengths and unmet needs  FORMTEXT      Goals for next twelve months  FORMTEXT      DESCRIPTION OF INTERVENTIONS NEEDED TO MEET THE GOALS (Identify tasks, activities or methods to achieve the goals)SERVICE CONTRIBUTIONHCN FUNDING REQUEST (Y/N) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Outcome measure How will the team measure achievement of goals ?  FORMTEXT       Specify baseline measure(s)  FORMTEXT       REVIEWS  REVIEW OF INTERVENTIONS FOR LIFE SKILLS DEVELOPMENTProvide detailsReview 1 What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? 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0644 laf4p |||}}wdd$ xx$Ifgd68$ xxgdIykd%b$$Ifl4#F$ ` t uݳ0644 laf4p uݳ}}b}d}gTT$ xx$Ifgd68kdb$$Ifl40x#b `` t0644 laf4pd}f}}~~gXI8 xx$Ifgd68 x$Ifgd68 x$Ifgd68kdc$$Ifl40x#b `` t0644 laf4p~~~gZ $<$Ifgd68kdd$$Ifl40x#b `` t0644 laf4p~~:~;~rr$ xx$Ifgd68ykde$$Ifl4#F$ ` t uݳ0644 laf4p uݳ;~<~a~b~gTT$ xx$Ifgd68kdf$$Ifl40x#b `` t0644 laf4pb~c~~~~gXI8 xx$Ifgd68 x$Ifgd68 x$Ifgd68kdg$$Ifl40x#b `` t0644 laf4p~~~gZ $<$Ifgd68kdh$$Ifl40x#b `` t0644 laf4p~~~~rr$ xx$Ifgd68ykdi$$Ifl4#F$ ` t uݳ0644 laf4p uݳ~~gTT$ xx$Ifgd68kdGj$$Ifl40x#b `` t0644 laf4p3cdgXI8 xx$Ifgd68 x$Ifgd68 x$Ifgd68kdKk$$Ifl40x#b `` t0644 laf4pdengZ $<$Ifgd68kdOl$$Ifl40x#b `` t0644 laf4pnorr$ xx$Ifgd68ykdSm$$Ifl4#F$ ` t uݳ0644 laf4p uݳgTT$ xx$Ifgd68kdn$$Ifl40x#b `` t0644 laf4pgXI8 xx$Ifgd68 x$Ifgd68 x$Ifgd68kdo$$Ifl40x#b `` t0644 laf4p ZgbbbbbY $IfgdSgdbkd p$$Ifl40x# b  `` t06uݳuݳ44 laf4p 046XZ\|ĽxgOx7xg.jh`4CJOJQJU^JaJmHnHu/jqh68hbCJOJQJU^JaJ h68hbCJOJQJ^JaJ)jh68hbCJOJQJU^JaJ h68h~OCJOJQJ^JaJ h68hbCJOJQJ^JaJ hvhb hC1(hb 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6^`K>>.$xx$Ifa$gd68 xx$Ifgd68kdb$$Ifl4 F4<#  t0S     44 laf4p`bdKF77 x$Ifgd68gd{Okd[$$Ifl4 F4<#  t0S     44 laf4p`bd FH\^`jlnprŰoŰWoF8h<CJOJQJ^JaJ h68hbCJOJQJ^JaJ/jh68hbCJOJQJU^JaJ.jh`4CJOJQJU^JaJmHnHu/jlh68hbCJOJQJU^JaJ h68hbCJOJQJ^JaJ)jh68hbCJOJQJU^JaJ#h68hb6CJOJQJ^JaJ h68hbCJOJQJ^JaJ h= htD h68htDCJOJQJ^JaJFnprtvxjeeeeX $<$Ifgd68gdbukdT$$Ifl#F$   t 0S44 lap  x$Ifgd68 xx$Ifgd68 rtvx CDjkǎlmwʏˏ$8:NnnnlnU h68htwCJOJQJ^JaJhCJOJQJ^JaJ#h68h05CJOJQJ^JaJ h68h0CJOJQJ^JaJ h68h0CJOJQJ^JaJ#h68hb5CJOJQJ^JaJ hvh&CJOJQJ^JaJhCJOJQJ^JaJhbCJOJQJ^JaJ* t$ x$Ifgd68ykd$$Ifl4#F$  t 0644 laf4p  x $<$Ifgd68ykd×$$Ifl4#F$ ` t 0644 laf4p BCwdd$ xx$Ifgd68$ xxgdIykdq$$Ifl4#F$ ` t uݳ0644 laf4p uݳCDijgTT$ xx$Ifgd68kd$$Ifl40x#b `` t0644 laf4pjkgXI8 xx$Ifgd68 x$Ifgd68 x$Ifgd68kd#$$Ifl40x#b `` t0644 laf4pƎgZ $<$Ifgd68kd'$$Ifl40x#b `` t0644 laf4pƎǎrr$ xx$Ifgd68ykd+$$Ifl4#F$ ` t uݳ0644 laf4p uݳgTT$ xx$Ifgd68kdٜ$$Ifl40x#b `` t0644 laf4p;klgXI8 xx$Ifgd68 x$Ifgd68 x$Ifgd68kdݝ$$Ifl40x#b `` t0644 laf4plmvgZ $<$Ifgd68kd$$Ifl40x#b `` t0644 laf4pvwrr$ xx$Ifgd68ykd$$Ifl4#F$ ` t uݳ0644 laf4p uݳɏʏgTT$ xx$Ifgd68kd$$Ifl40x#b `` t0644 laf4pʏˏ68gXI8 xx$Ifgd68 x$Ifgd68 x$Ifgd68kd$$Ifl40x#b `` t0644 laf4pte funding change request)Review 4What progress has been made towards goals?Have the outcomes been achieved?Please provide report on outcome measures (Attach if a report) Wellbeing Framework: PEER AND SOCIAL RELATIONSHIPSRelevant history / rationale  FORMTEXT      Current situation, including strengths and unmet needs  FORMTEXT      Goals for next twelve months  FORMTEXT      DESCRIPTION OF INTERVENTIONS NEEDED TO MEET THE GOALS (Identify tasks, activities or methods to achieve the goals)SERVICE CONTRIBUTIONHCN FUNDING REQUEST (Y/N) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Outcome measure How will the team measure achievement of goals ?  FORMTEXT       Specify baseline measure(s)  FORMTEXT       REVIEWS  REVIEW OF INTERVENTIONS FOR PEER AND SOCIAL RELATIONSHIPSProvide detailsReview 1 What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 2What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 3What progress has been made towards goals?Do the interventions need to change?Does the budget need to change? (If yes please complete funding change request)Review 4What progress has been made towards goals?Have the outcomes been achieved?Please provide report on outcome measures (Attach if a report) Section 3: Funding requests Wellbeing Framework: SERVICES COORDINATOR CONTRIBUTIONQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL REQUEST TO HCNPlan Development fee FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Contribution to Services Coordinator  FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total Services Coordinator contribution =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 HCN funding request: LIVING ARRANGEMENTSRESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL REQUEST TO HCN FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total request living arrangements =sum(above) 0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 HCN funding request: WHNAU/FAMILY RELATIONSHIPSRESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL REQUEST TO HCN FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total request whnau/family relationships =sum(above) 0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 HCN funding request: EDUCATIONAL/VOCATIONAL NEEDSRESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL REQUEST TO HCN FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total request educational/vocational needs =sum(above) 0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 HCN funding request: HEALTH AND DISABILITYRESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL REQUEST TO HCN FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total request health and disability =sum(above) 0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 HCN funding request: EMOTIONAL WELLBEINGRESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL REQUEST TO HCN FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total request emotional wellbeing =sum(above) 0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 HCN funding request: CULTURAL IDENTITYRESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL REQUEST TO HCN FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total request cultural identity =sum(above) 0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 HCN funding request: LIFE SKILLS DEVELOPMENTRESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL REQUEST TO HCN FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total request life skills development =sum(above) 0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 HCN funding request: PEER AND SOCIAL RELATIONSHIPSRESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL REQUEST TO HCN FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total request peer and social relationships =sum(above) 0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 SUMMARY LIST OF OUTCOME MEASURES TO BE USED FOR THE PLAN FORMTEXT       PLAN START DATEWhat is the anticipated start date for the plan once approved? (mm/yy)  FORMTEXT       CRISIS PLANList potential crises that are most likely for this child or young person.POSSIBLE CRISISLIKELY IMPACTIMMEDIATE RESPONSE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Funding change request  REVIEW 1RESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL CHANGE REQUEST FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0 FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0 FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total review 1 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(left) \# "#,##0"  0 Lead agency manager sign-off to funding change requestI have read this review, provided a funding report and support the changes in the interventions outlined.Name First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Signature: Date: Funding change request  REVIEW 2RESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL CHANGE REQUEST FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0 FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0 FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total review 2 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(left) \# "#,##0"  0 Lead agency manager sign-off to funding change requestI have read this review, provided a funding report and support the changes in the interventions outlined.Name First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Signature: Date: Funding change request  REVIEW 3RESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL CHANGE REQUEST FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0 FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0 FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total review 3 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(left) \# "#,##0"  0 Lead agency manager sign-off to funding change requestI have read this review, provided a funding report and support the changes in the interventions outlined.Name First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Signature: Date: Funding change request  REVIEW 4RESOURCES REQUESTEDRATEQTR 1 $QTR 2 $QTR 3 $QTR 4 $TOTAL CHANGE REQUEST FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0 FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0 FORMTEXT       FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 FORMTEXT 0 =sum(left) \# "#,##0"  0Total review 4 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(above) \# "#,##0"  0 =sum(left) \# "#,##0"  0 Lead agency manager sign-off to funding change requestI have read this review, provided a funding report and support the changes in the interventions outlined.Name First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Signature: Date: Section 4: Local manager sign off LEAD AGENCY MANAGER SIGN-OFFAs Lead Agency Manager I agree to: manage the approved funding and ensure quarterly reporting on progress, outcomes for the child/ young person and expenditure enter into service agreements with providers in this plan that meet my agency s quality assurance standards and processes and related contracting requirements contract and support the Services Coordinator for this plan.Lead Agency ManagerSignature: Date:Name First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Employer:  FORMTEXT      Email:  FORMTEXT      Phone:  FORMTEXT      Mobile:  FORMTEXT      Fax:  FORMTEXT      Address Street address:  FORMTEXT       Postal address:  FORMTEXT       OTHER AGENCY MANAGER SIGN-OFFI agree to support the implementation of this plan and agree that the interventions proposed in this plan are consistent with goodpractice.Agency managerSignature: Date:Name First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Employer:  FORMTEXT      Email:  FORMTEXT      Phone:  FORMTEXT      Mobile:  FORMTEXT      Fax:  FORMTEXT      Address Street address:  FORMTEXT       Postal address:  FORMTEXT      Agency managerSignature: Date:Name First name:  FORMTEXT       Last name:  FORMTEXT      Role title:  FORMTEXT      Service name:  FORMTEXT      Employer:  FORMTEXT      Email:  FORMTEXT      Phone:  FORMTEXT      Mobile:  FORMTEXT      Fax:  FORMTEXT      Address Street address:  FORMTEXT       Postal address:  FORMTEXT       Section 5: Form feedback FORM FEEDBACKThe HCN Unit appreciates feedback on its forms. Please provide comments or suggestions here or send them to  HYPERLINK "mailto:hcn@govt.nz" hcn@govt.nz with  feedback on plan form in the subject line.  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ǟġP[ATʩ$,i$老p~$PTU$TU$CYPѺg|ڒ?\o7YSn_8$?9r?)?V+'?XlI ?H[oXYOI?ޏ8ɸI;F.6  ?޾xI@?ܗlHw/DPhotoshop 3.08BIM%8BIM com.apple.print.PageFormat.PMHorizontalRes com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMHorizontalRes 72 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2007-03-19T04:36:48Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMOrientation com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMOrientation 1 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 2007-03-19T04:36:48Z com.apple.print.ticket.stateFlag 0 com.apple.print.PageFormat.PMScaling com.apple.print.ticket.creator com.apple.printingmanager com.apple.print.ticket.itemArray com.apple.print.PageFormat.PMScaling 1 com.apple.print.ticket.client com.apple.printingmanager com.apple.print.ticket.modDate 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