STATE OF NEW HAMPSHIRE
Department of Health and Human Services
Division for Children, Youth, and Families
Form 2291
December, 1999
ADULT LIVING PREPARATION PLAN
Name of Youth: John Doe
Today’s Date: MM/DD/YYY
DOB: MM/DD/YYYY Age:
Current Placement: Becket Family of Services
Expected Exit Date:
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1. EDUCATION & EMPLOYMENT
HS / GED / Vocational / Trade School / Job Prep / On-the-Job / Employed
F
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Achievements: John is currently enrolled in 9 grade classes at Mount Prospect Academy. John is earning passing grades
in his courses, and has made significant gains over the course of his programming at MPA. John does however have a
history of disruptive and destructive behaviors within the classroom setting. Recently however, those have significantly
decreased as evidenced by his academic behavioral data tracking. John has the ability to earn a total of 28 points per day
on his academic data tracking sheets. In review of the most recent three months, John has been averaging 24.56 points per
day. This indicates an 8.72 point improvement from the previous three month rating period. John has decreased his
instances of leaving campus unsupervised and has actively worked towards utilizing his various supports. John has been
motivated by receiving additional support from paraprofessionals in the Student Support and Becket Interactive
Educational Environment (BIEE) classrooms when he becomes overwhelmed. John has increased time spent in classes
and has also begun to interact more appropriately with his peer group.
Needs/Action/Plan: John needs to continue academic programming in order to obtain high school credits and ultimately
achieve a high school diploma. John’s programming also needs to include vocational training, in order to provide John
with life skills and abilities that will enable him to maintain independent living skills once graduation.
John is a special education student, with a primary disability of Emotional Disturbance, through the Nashua School
District. John struggles in the academic setting, especially with his attention and focus within the classroom. John requires
individualized supports due to his easily frustrated nature, and constant need for prompting and redirections during tasks.
When motivated, John does an excellent job and is capable of completing grade level work. John does well when allowed
to listen to music and many times uses music as an alternative for assignments, mostly within his English class. John will
continue to program in grade level courses, and have the opportunity to attend vocational sites that are tailored to his
needs – John will continue to have access to his academic case manager, clinical supports, and Permanency Team as he
progresses through programming.
Becket Family of Services and Mount Prospect Academy provide continuing pre-vocational and vocational training both
on site and in off-campus work sites. Job preparation is a major focus. In his vocational work and in the Adult Living
Group, he will continue to obtain job-related skills and information.
2. PERSONAL CARE, HEALTH, & SAFETY
Hygiene / Medical History / Medications / Emergency Medical Treatment
Achievements: Personal Care, Health, & Safety
In John’s participation in residential life with the Becket Family of Services, he has demonstrated some awareness of
proper hygiene. He is engaged in receiving ongoing medical care to meet his needs and meets once monthly, or as needed
otherwise, with Dr. Richard Hattan for psychiatric care and compliance with his medication management. John has access
to Emergency Medical Care through the Becket Family of Services Registered Nurses, faculty trained in basic first aid as
well as emergency care through community based providers such as Speare Memorial Hospital and Mid-State Health
Center located in Plymouth NH.
In his residential setting, John has exhibited an awareness of age appropriate personal hygiene. Overall, he has been in
good health; eye physical, dental exams however, there is a family history of depression (his mother). John has been
meeting regularly with the psychiatrist and understands the general needs of his ongoing medication compliance. John last
had a annual medical exam on 10/14/12 where he was found to have no medical concerns with the exception of acne. He
was recommended to engage in a consumption of healthy meals and participate in physical exercise regularly. John is
currently taking the following medications: Betamethasone, Abilify 20 mg, Lithium ER 450 mg, and Abilify 10 mg to
assist in supporting his mental health diagnoses.
John needs support regarding taking care of his own laundry, purchasing clothes, and knowing why it is important to see
the doctor and the dentist.
Needs/Action Plan: John needs ongoing support regarding basic information pertaining to his medications, avoiding
sexually transmitted diseases and controlling his acne. He needs basic training in first aid and CPR. He will be provided
this information in scheduled group counseling sessions which occur every week which focus on daily living and prevocational skill acquisition. Upon discharge, John will probably live with his mother, Ms. Doe in Manchester NH. His
school district, Permanency Specialist, CASA worker, and DCYF worker, will coordinate plans for his successful
discharge into the community, if such living arrangements are possible for him. He is presently on Betamethasone 0.05%
Lotion, 450 mg. of Lithium ER to help with managing moods, 10 mg. of Abilify to help with depression, 20 mg. of
Abilify to help with depression. In the residential setting with Becket, he needs encouragement to do his own laundry.
John will continue to be provided with ongoing counseling pertaining to personal hygiene and independent living skills
within the residential milieu.
Materials used will be those from the Life-Centered Career Education Curriculum and the NH T.R.A.I.L.S. curriculum.
Individual and Group Therapy will address those issues which will prohibit John from living comfortably and safely with
others upon his transition into the community setting. Also, residential living within the programs at the Becket Family of
Services helps students deal with issues of personal care, health, & safety on a daily basis.
PD 99-33
YOUTH: John Doe
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3. BEHAVIOR/SOCIAL SKILLS
Family & Peer Relationships / Supports / Communication Skills / Adult Advocate
Achievements: John’s social skills, as evidenced in his Becket Family of Services Self-Management Tracking Notes and
Classroom Behavior Checklists, are below average. He responds in a friendly manner when approached by adults or other
peers he trusts and has respect for. John however struggles to initiate positive, appropriate social contact with others when
he feels that he does not have a positive relationship with them. John does however have the ability to remain truthful and
responsible pertaining to interpersonal relationships. His relationship with his family has improved steadily over his stay
with Becket. John’s grandmother has been a consistent support for him and his permanency team continues to work to
improve upon his overall relationships with his family and peers in the community setting. John possesses basic verbal
communication skills overall and can effectively advocate his wants and needs appropriately.
John’s father lives in Manchester New Hampshire and has limited contact with John. John does not have visits with his
father, but does have some phone contact with him. He is able to see his mother in her home weekly as well as his two
older siblings. John has a CASA worker who is consistently involved in the decision-making process for John and acts as
an advocate for him. In both individual and group therapy, he continues to work on establishing better relationships with
authority figures and that he learns to communicate his fears and doubts in a constructive as opposed to a destructive
manner.
Needs/Action Plan: As part of his discharge plan, it is anticipated that John will need to participate in ongoing
therapy in order to work on mental health issues and interpersonal relations skills. While with Becket, John will
participate in groups/counseling regarding anger management, social skills, empathy, and adult living on a weekly
basis to address the issues facing students when they transition back to the community and into independent living
situations. Also, residential living at Becket will help John improve his performance in many areas, including
personal-social skills. He also participates in a 24- hour behavior management plan to assist in supporting his
individual needs. In particular, John needs to develop respect for the rights and properties of others, be able to
demonstrate appropriate behavior in public, be aware of how his behavior affects others, and to be able to recognize
and respond to emergency situations.
Becket’s residential programs, individual therapy, and group therapy (including Adult Living Group) provide a constant
emphasis on behavior and social skill improvement. Students participate in a 24- hour behavior management plan. A
major emphasis of the program is to improve family and peer relationships so that the student may return to his home and
community.
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HOME, FOOD, & MONEY MANAGEMENT
Menu Planning / Budgeting & Savings / Adult Housing Options / Obtaining Household Items / Shopping
Skills
Achievements: During his stay with Becket Family of Services residential program, John has gained several daily living
skills. He is able to purchase food, clean food preparation areas, learn how to store food and prepare meals, demonstrate
appropriate eating habits, and plan and eat balanced meals. He has purchased his own clothing, can wash and iron his own
clothing with limited prompting and is able to develop a balanced budget. He is able to handle his own personal money,
including counting money and making change. He is able to save for future purchases as evidenced by his ability to
purchase gifts for his family. He is able to shop for household and personal items with support from faculty while in the
community setting.
Needs/Action Plan: John needs to continue in depth training in basic living skills, including money management,
shopping on a budget, nutrition, home cleanliness, etc. These issues will continue to be addressed both in the residence on
a daily basis and in group meetings on a weekly basis, utilizing the Life-Centered Career Education Curriculum, materials
from the DCYF Adult Living program, and materials from the University of New Hampshire Extension.
Presently, John’s residential situation provides skill development in money management, including understanding the
value of money, opening a savings account, and understanding the functions of banks. John would benefit from opening a
bank account and working to save financially.
In the Becket Family of Services Adult Living Group, John will continue to develop his money management skills through
utilization of Adult Living Program materials and the NH Extension Money Management Curriculum. In the group, he
will also learn about living on his own, including the cost of housing, finding a place to live, sharing housing with a
roommate, how to find inexpensive furniture at yard sales, used furniture stores, etc., what kind of bills to expect for
utilities, telephone, etc. Combined with functional curriculums and the Adult Living Group, provides students with many
of the skills necessary for coping in independent living situations, including shopping, planning menus, creating a budget,
opening a savings account, searching for housing, etc. Residential life presents numerous opportunities for students to
learn which foods are nutritious, purchase food frugally, cook simple meals, plan menus, store food, keep living areas
clean, use appropriate cleaning supplies and equipment, and to perform basic household maintenance.
YOUTH: John Doe
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5. TRANSPORTATION, LAW, & COMMUNITY
Driver's License / Car Insurance / Public Transit / Legal Status / Extended Jurisdiction / Community
Connections
Achievements: John has begun discussion with his treatment team regarding his ability to earn his driver’s license with a
community based provider. He knows how to utilize public transportation and has done so on several occasions during
community based outings. John has basic knowledge regarding the need of obtaining car insurance and laws pertaining to
him. He has engaged in conversations with his permanency and treatment team pertaining to extended jurisdiction and the
possibilities for him that this could provide. John has several community connections and is able to communicate with
approved individuals from his community of origin.
Needs/Action Plan: John will likely benefit from obtaining a driver’s license. He will be encouraged to apply for
scholarships to assist in offsetting the cost associated with this course. John will continue to engage in activities centered
on improving his community based connections and understanding the use of public transportation. John’s probation
officer, DCYF worker and lawyer will continue to provide John with information pertaining to the possibility of extending
jurisdiction. Becket faculty members and John’s treatment team will continue to facilitate communication pertaining to
appropriate services, living arrangements, etc. Once he is living in a community, the aftercare team will continue to assist
in acquainting him with the community, transportation and recreational options.
In the Becket Family of Services Adult Living Group, students will investigate the cost of car insurance and the legal
consequences if he drives without insurance. He will also learn about community resources such as social service
agencies and crisis hotlines, local legal aid and public defender services, and local employment services. Students will
also learn about their civil rights. Students also have the opportunity to obtain their driver’s license in a certified driver’s
education program providing that certain requirements and separate funding is available.
6. FUTURE INCOME NEEDS, PERSONAL NEEDS, & COMMUNITY LIVING
Birth Certificate / S.S. Card / Educational Information / Medical History / Medical Care, Rx, Insurance
Needs
Achievements: John is on the path to a successful graduation from high school given his current performance and
standing. He has his birth certificate and social security card. John has access to information within his medical history
and meets regularly with medical professionals as indicated. John’s physicians have been able to support him in obtaining
his medical prescriptions currently. Lastly, John has insurance provided to him through the NH Healthy Kids Goal
program and he is aware of the overall needs to maintain this standing.
Needs/Action Plan: Prior to John’s transition from the residential setting with the Becket Family of Services, John
and his treatment team will work to obtain all information supporting his academic needs. John will be required to
tour the new school he will be attending as well as meet with the academic professionals in the classroom setting.
John will be provided with a 30 day discharge prescriptions for his medications and his treatment team will need to
work to establish ongoing support from community based providers prior to transition. John should be provided
with a resource binder including copies of his birth certificate, social security card, academic transcripts, medical
history and insurance information.
In the Becket Family of Services Adult Living Group, students will learn about options for medical care when he is
on his own, such as local community based clinics, Alcoholics Anonymous, family planning services and community
centers. He will learn how to care for important documents. He will learn about various hotlines in the state and/or
his community, which can help him find shelter, food, and a job. Students will continue to utilize materials supplied
by the Adult Living Program, such as NH T.R.A.I.L.S. Becket’s transition plan will set in motion the process for
establishing ongoing community based supports. His medical history is on file at MPA and will follow him into the
community. Medical care, prescriptions, etc. will be provided through Medicaid.
Persons Involved With Case
Relationship to Youth
Date
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NOTE: Date youth received the ILP Info Packet: ___/___/_____.
Name of person who completed this form: _______________________________________________
Other _______________________________
CPSW or JPPO _______________________________
STATE OF NEW HAMPSHIRE
Department of Health and Human Services
Division for Children, Youth, and Families
Form 2291(i)
December, 1999
Instructions to the “Adult Living Preparation Plan”
PURPOSE:
The “Adult Preparation Living Plan” is used to identify adult living preparation life skill information. Youth in
foster care who are age 15 and older must have a plan explaining what the youth's needs are who are making the
transition from foster care. The plan is developed from the program’s “Needs Assessment” and a life skills
assessment. The ALP plan reflects the residential treatment plan which is a required of residential providers under
the Certification for Payment Standards. The federal requirements of the IL grant mandate that all youth at a
specific age have a plan identifying how they will be prepared to make the transition to adulthood.
INSTRUCTIONS:
Form 2291 is a 4 page template completed by the substitute care provider and the youth, with assistance from the
CPSW, JPPO, the IL Coordinator, and family members.
The form must be completed within 30 days of the date of the youth's placement or within 30 days of the youth's
15th birthday.
Form 2291 is attached to the “Case Plan” (Form 2240). One copy is filed in the record and one copy is forwarded to
the substitute care provider.
FORM COMPLETION:
Enter the current date.
Enter the name of the youth, his or her date of birth, and present age.
Enter the name of the youth's current provider and the date the youth is expected to exit foster care.
Under each of the 6 categories, enter what the youth has achieved to date and what the youth needs to achieve
within his or her timeframes for adult living preparation. For each need identified, specify how the youth will
accomplish or be assisted in accomplishing the plan.
Complete page 4 on all youth who are age 17 or older or who are within 6 months of leaving placement.
The youth, the substitute care provider, CPSW, JPPO, parent (optional), or others sign and date the form.
RETENTION:
Form 2291 is permanently retained in the case record or file.
PD 99-33