St. Luke s LifeWorks Person-Centered Assessment and Recovery Support Plan Form Revised As of 9/30/2008

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1 St. Luke s LifeWorks Person-Centered Assessment and Recovery Support Plan Form Revised As of 9/0/008 Name: Date of Birth: Date Completed: Participant ID#: PART A: Person-Centered Assessment Introduction: Today I am going to be asking you a lot of questions about what things in your life are going well, and what things you might like to change. Some of the questions might be things like: Tell me about the people that are important to you? And, what are your dreams for the future? We think that this information can be a very important part of your treatment and recovery. It will be helpful to us as we work together to develop a recovery plan that fits with your unique goals and priorities. Sometimes it can also be useful to get ideas from people who are important to you or who have helped you out in your recovery. Let s make a list of these people. In addition to clinicians or other providers, think about including supportive friends, family, employers, or clergy members. These people may play some part in helping you to carry out your recovery plan and action steps. Name Relationship to you How has s/he been supportive? OK to contact? yes Hopes & Dreams. What are your hopes and dreams for the future? What are some of the most important things you want to have in your life?. If you could change anything in your life right now what would it be?

2 Strengths & Interests. To help you meet your goals we need to think about what strengths you have. Sometimes people have a hard time remembering their strengths. The following statements may help you get ideas. My best qualities as a person are I am most proud of People like that I am (people say they like my) The times I am most at peace are when I notice my problems the least when I am The things that help me to make it through the day when I am down are. Could you tell me about some of your interests or skills? When you answer the question think about things you: Enjoy doing at home or in you neighborhood/town?...are interested in or would like to learn more about?...like to show other people how to do?...used to feel good about before you began to have mental health difficulties/substance abuse problems, etc., Care a lot about (like kids or friends or animals)? Complementary Plans & Documents. Do you have an Advance Directive? Y N. Do you have a WRAP Plan or other wellness plan? Y N Note: Persons with advance directives and/or wellness plans should be encouraged to share those with the team as means of informing development of this Recovery Plan. Persons without advance directives or wellness plans should be educated about these tools and referred for support if interested. RECOVERY AREAS Now we re going to take closer look at different parts of your life. In each section, I will ask you to rate how things are going, and to decide whether or not you d like to work on that area as a part of your Recovery Plan.. WHERE YOU LIVE (HOUSING/NEIGHBORHOOD) (LLL FOCUS: HOUSING) Tell me a bit about your current living situation (house, apartment)? What is working/not working for you? How do you feel about the place where you live? Very / Serious Very /No

3 . FAMILY & OTHER RELATIONSHIPS (LLL FOCUS: ESSENTIAL LIFE SKILLS) How are your friendships/family relationships going? How do friends/family respond to your (interviewer choose most relevant): mental health issues/substance abuse/homelessness/health issues? Is there anything you d like them to understand better? How do you feel about your relationships with friends and family? Very / Serious Very /No. MONEY/FINANCES (LLL FOCUS AREA: INCOME SUFFICIENCY) How is your current financial situation? Are you stressed about money? Does anyone help you with managing your money? Would you like to be more independent with this? How do you feel about your financial situation? Very / Serious Very /No. WORK (LLL FOCUS AREA: EMPLOYMENT) Are you working right now? If so, where? Are you happy with this job? Have you worked in the past? If so, what did you like best/least about these positions? How about volunteering? How do you feel about your work situation? Very / Serious Very /No

4 . EDUCATION/TRAINING/PERSONAL DEVELOPMENT (LLL FOCUS : EDUCATION) What was school like for you and how far did you go? Are you satisfied with this? Are there things you would just like to learn more about, e.g., taking classes in a talent or a hobby? How do you feel about your education? Very / Serious Very /No 6. FUN, LEISURE, & DAILY ROUTINE (LLL FOCUS: ESSENTIAL LIFE SKILLS) How do you feel about your daily routine? Very / Serious Very /No 7. SPIRITUALITY (LLL FOCUS: MENTAL HEALTH) How do you feel about your spirituality/faith practice? Very / Serious Very /No

5 8. MENTAL HEALTH/SYMPTOMS (LLL FOCUS: MENTAL HEALTH) What types of symptoms do you experience, and how much do these interfere with your life? Have you had experiences of trauma, e.g., have you ever been treated in ways that were harmful to you (e.g., physical or sexual abuse, etc.)? If so, can you tell me about how you were affected and what you have done to deal with it? What types of mental health supports are you currently involved in? Do you find these helpful? Are medications a useful tool in your recovery? Do you have concerns about your meds? What else do you do to cope with your symptoms? How do you feel about your mental health symptoms? Very / Serious Very /No 9. DRUGS AND ALCOHOL (LLL FOCUS: PHYSICAL HEALTH) Do drugs and/or alcohol influence your life right now? If so, how? What types of services & supports have been helpful in the past in managing problems with drugs or alcohol? Do you use community supports such as AA or NA to maintain recovery? How do you feel about the effect of drugs and alcohol on your life? Very / Serious Very /No

6 0. SAFETY (LLL FOCUS: MENTAL HEALTH/PHYSICAL HEALTH) Do you ever feel that you are at risk to hurt yourself or someone else? When you are not doing well, do you have a hard time with controlling your anger or having verbal or physical outbursts? What do you do to control these risks (if applicable)? Do you ever think about suicide or hurting yourself? What makes you feel more safe? How do you feel about your ability to control verbal or physical outbursts? Very /Serious How do you feel about your own safety? Very /Serious Staff Comments: Very /No Very /No. LEGAL ISSUES (LLL FOCUS: PERSONAL RESPONSIBILITY) What, if any, legal issues are you dealing with right now? (e.g., court appearance, probation requirements, etc.) What are the offenses for which you have these legal commitments? If you have any legal commitments do you understand these and/or would you be interested in learning more about your responsibilities? How do you feel about your legal issues? Very / Serious Very /No

7 . RIGHTS, CHOICE-MAKING, AND ADVOCACY (LLL FOCUS: PERSONAL RESPONSIBILITY) Have you ever felt like you were discriminated against (e.g., in housing, job applications, etc.) based on having mental health problems? Do you know what your rights are and how to protect them? In your services at St. Luke s, if you are unhappy with your care, do you know how to express your dissatisfaction and get a response? What are the some of the choices that you currently make in your life? Are there choices that are made for you, and if so, how do you feel about this? Have you ever been involved in advocacy activities for people with mental health issues, or would you like to become involved in such activities? How do you feel about your ability to protect your rights and make choices in your life? Very / Serious Very /No. PHYSICAL HEALTH & WELL-BEING (LLL FOCUS: PHYSICAL HEALTH) Do you have any specific medical problems or concerns about your health? Are you getting enough rest and exercise? If you smoke are you interested in trying to quit? How about allergies or special diets or nutritional needs, e.g., for diabetes? How do you feel about your physical health and well-being? Very / Serious Very /No. OTHER ISSUES Are there other things that are important in your recovery that we have not covered so far? How do you feel about this area of your life? Very / Serious Very /No

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