GT-6CE-Leaving-Plan-Care-F

Sep 11, 2026

Uploaded by Levi

This document provides a sample Plan of Care for healthcare transition, designed to be collaboratively developed by youth and their parent/caregiver. It integrates health and personal goals, using information from transition readiness assessments to set actionable objectives. The plan emphasizes frequent updates and inclusion in the transfer package to the new adult clinician. It includes sections for preferred and legal names, date of birth, primary and secondary diagnoses, and a critical question: 'WHAT MATTERS MOST TO YOU AS YOU BECOME AN ADULT? HOW CAN LEARNING MORE ABOUT YOUR HEALTH NEEDS AND LEARNING HOW TO USE HEALTH CARE SUPPORT YOUR GOALS?'. The core of the plan is a table to detail youth's prioritized goals, transition issues or concerns, corresponding actions, responsible parties, target dates, and completion dates. It also includes spaces for clinician/care staff information, signatures, and dates of creation/update, along with youth and parent/caregiver signatures, reinforcing the collaborative and documented nature of the transition process. This sample plan adheres to the Six Core Elements of Health Care Transition™ 3.0 framework, copyright © 2020 by Got Transition®, permitting non-commercial use with proper attribution.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

THE SIX CORE ELEMENTS OF HEALTH CARE TRANSITION™ 3.0

Sample Plan of Care

Youth’s Prioritized Goals

Transition Issues or Concerns

Actions

Person Responsible

Target Date

Date Completed

Clinician/Care staff name

Clinician/Care staff contact information

Clinician/Care staff signature

Youth signature

Parent/Caregiver signature

Transitioning Youth to an Adult Health Care Clinician

Six Core Elements of Health Care Transition™ 3.0

FAQs

What is the primary purpose of this sample Plan of Care?

The sample Plan of Care is created jointly with youth and their parent/caregiver to set goals and outline a plan of action that combines health and personal goals for the transition to adult healthcare.

What information is included in the sample Plan of Care?

The plan includes spaces for personal and medical information, prioritized goals, transition issues, actions, responsible parties, target dates, and completion dates, along with signatures from the youth, parent/caregiver, and clinician.

How often should the Plan of Care be updated?

The Plan of Care should be updated often and sent to the new adult clinician as part of the transfer package.

Sep 11, 2026

Uploaded by Levi