• Work in partnership with the people we support and from a strengths-based perspective to assess their individual needs, hopes, and dreams using the principles of Person-Centered Planning.
• Facilitate the development of the Person-Centered Plan in a format appropriate for each person and aligned with CQL standards during annual and semi-annual reviews of individuals on caseload; facilitate a collaborative, effective, and efficient team process.
• Ensure that friends and families are fully involved in the planning if this is what the person wants.
• Facilitate the development of an action plan in partnership with the people supported and their families to allow them to take control of their short and long-term goals.
• Support the person and/or the family to develop the strategies to reach these goals.
• Facilitate the development, tracking, and updating of these person-centered, assessment-based, and functionally-adaptive goals, the input of those goals into clinical documentation system, in-service as needed, and ongoing staff-training with a focus on Person-Centered Planning with related documentation.
• Work with other support providers to identify, plan and ensure a range of individual programs and activities to promote personal resilience and improve access to mainstream community inclusion. This includes facilitating visits to local colleges, community organizations, recreational activities or other mainstream locations to enhance the opportunity for inclusion and choice for each person we support.
• Facilitate personal development programs tailored to the individual needs, hopes and dreams of the people we support.
• Work with circles of support to ensure that the professionals, services and agencies involved are aware of their roles in ensuring that people achieve their wishes and aspirations.
• Coordinate and facilitate circle meetings for individuals with appropriate documentation of each meeting.
• Promote the values and principles of inclusion, dignity, opportunity, rights, choice and independence in the community.
• Provide counseling as needed with individuals, especially as related to person centered planning and crisis situations.

Collaboration:

• Make referrals for consultations by other professional disciplines and/or therapy as indicated. Attends provider appointments as necessary.
• Act as a liaison and advocate ensuring compliance with Person Centered Planning regarding mental health services/behavioral issues between and among all team members, clinics, day programs, families, and hospitals and concerned others.