Module 12, Session 4, handout 6

Integrating the Wraparound Process in
Alternative Education Setting :
The Steps of the Wraparound Process

Lucille Eber Ed.D.
Statewide Coordinator
Illinois Emotional/Behavioral Disabilities (EBD) and
Positive Behavioral Interventions and Supports (PBIS Network)

~ Module 12, Session 4 ~

Handout 6:
Collaborative Team Planning Form (CTPF)--Revised

Youth Name:____________________

Referral Date:__________________

Dates of Conversations with Core Team Members:_______________________________

# Planning Step 1: Hearing the Family & Teacher(s) Story through Initial Conversations

	Core Team Members	Role
1
2
3
4
5
6
7
8

	Extended Team Members	Role
1
2
3
4
5
6
7
8

IMMEDIATE SAFETY PLAN (describe specific safety needs; strengths and strategies):

Date	Perspective y - youth f - family s - school c - community	Domain (see key at bottom of page)	Strengths, interests and current/past successful strategies
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C
	Y F S C

Domain Key:

fs-family support
l - legal

ls-living situation
hm - health/medical

s – safety
b - basic needs

ev - educational/vocational
sr - social/recreational

csp - cultural/spiritual
eb – emotional/behavioral

Issues and perspectives for future planning (draft need statements)	Date	Perspective y - youth f - family s - school c - community	Domain (see key at bottom of page)
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C
		Y F S C

Domain Key:

fs-family support
l - legal

ls-living situation
hm - health/medical

s – safety
b - basic needs

ev - educational/vocational
sr - social/recreational

csp - cultural/spiritual
eb – emotional/behavioral

ACTION PLAN

Metting Date:_________________

Next Meeting Will Be (date & Time):__________________________________

Youth/Studetn:___________________

Parent Guardian:_________________________________

Facilitators:_____________________________

School Contact:_____________________________________

# Planning Step 2: Meeting & Follow-up Minutes

A. Present strengths to team/add strengths
B. Identify/clarify Team Roles
C. Present issues/concerns
D. Develop Mission Statement

CONFIDENTIALITY AND ATTENDANCE
I agree to honor the rights and privacy of any persons discussed in this meeting. I agree not to divulge any information regarding any family, person, or agency, which may be referred to in the course of this meeting.

Name - Please Print	Relationship

Mission Statement:

# Planning Step 3: Develop Action Plan with Monitoring

A. Identify the issue that is the target for change
B. Identify outcomes & related strengths that addresses needs
C. Prioritize specific outcomes
D. Develop strategies and gain commitments
E. Indicate progress at follow-up meetings

Domain to be addressed ______________________

Issue “What is the situation that needs to be changed?”	Outcome “What does life look like when it’s better?”	Strengths “What can we build on?”	Strategies “What’s it gonna take to make this kid/family look more like a kid/family that’s doing okay?”	Date for Follow Up	Actual Date of Follow Up						Barrier “What hurdle do we need to overcome?”
					N/A	1	2	3	4	5
					Comments:
					N/A	1	2	3	4	5
					Comments:
					N/A	1	2	3	4	5
					Comments:

Progress Update key
NA= no longer a need or goal
1= unresolved or worse; not attained
2= unchanged; still a need or goal
3= progress made but still a need
4= unresolved or partially attained
5= resolved or attained to satisfaction