Care Chexx Recuperative Care Case Plan Client's First Name Client's MI Client's Last Name Suffix (If Applicable) DOB: Race Gender Male Female Mobile Number Email Veteran Status Spouse of Veteran Yes - Enrolled w/ VA Yes - Not Enrolled w/ VA No Most Recent Housing Location Unsheltered (Street, Vehicle, Encampment) Emergency Shelter Transitional Housing Doubled Up Own Apartment/House Nursing Facility Correctional Facility Other Length of Time Homeless Barriers To Housing Income/Employment History Eviction Record Criminal History Substance Use Life Event (Death, Illness, Divorce, etc.) Other Barrier Narrative To Housing Stable Friend or Family Member Relationship Phone Number Government or Community Support Person Notes Mental Health Provider Contact Number Client Discharge Goals Care Plan Goals #1 Care Plan Goals #2 Staff Completing Case Plan Staff Title Staff Phone Number Staff Email Date Created Submit Case Plan Your Preferred Recuperative Care Provider
