P L A N D E S E R V I C I I

P L A N D E S E R V I C I I*

Nr. ______ / _____________

1. Date de identificare a persoanei asistate:

Numele i prenumele beneficiarului:_____________________________________________

Locul i data naterii:_________________________________________________________

CNP:_____________________________________________________________________

Act de identitate: CI/BI seria _________ numr ___________________________________

Categorie de beneficiar:

copil aflat n situaie de risc social

copil cu dizabiliti

persoan adult cu handicap

persoan aflat n situaie de risc social

Informaii despre copil:

Mama:______________________________________________________________

Tata: _______________________________________________________________

Reprezentantul legal: __________________________________________________

Diagnostic___________________________________________________________

Informaii despre persoana cu handicap:

Tip de handicap: ______________________________________________________

Certificat de handicap nr. ____________ din ________________________________

Grad de handicap: _____________________________________________________

Domiciliul conform actului de identitate:________________________________________

Locuind n fapt:_____________________________________________________________

Studii:____________________________________Meseria:__________________________

Dispozitie de internare nr._______________Centrul________________________________

Incadrat n munca la_________________Funcia___________________________________

Stare civil________________________Nr. copii_________________________________

2. Contract de servicii nr.____________________ din __________________________________

3. Serviciile care vor fi oferite i care rezult din evaluare / reevaluare:

Servicii de baz:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Servicii de suport:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Alte tipuri de servicii specifice beneficiarului:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Manager de caz: ____________________________________________________________

Echipa multidisciplinar:

Nume i prenume: Specialitatea:

Instituia:

1.

2.

3.

4.

5.

Familia/reprezentantul legal:

* Acest tip de plan de servicii nu este prevzut ca atare n legislaia n vigoare, ci este un model adaptat de Asociaia Vasiliada n conformitate cu necesitile i specificul serviciilor furnizate categoriilor de beneficiari aflai n eviden, excepie fcnd persoanele vrstnice, pentru care s-a pstrat modelul reglementat legal.