2022 Edition

Youth Psychosocial Services (CA-YPS) 3: Rehabilitation Team

The rehabilitation team consists of professionals that represent each sector providing services to the youth as well as the youth themselves, the primary caregiver, and any appropriate family members or natural supports.




Youth participating in Psychosocial Services receive community based services that facilitate childhood development and resiliency using a holistic approach that improves family functioning and increases child well-being and safety.
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Procedures or other documentation relevant to team coordination of care and case assignment
  • List of the rehabilitation team members and their roles (including child and family/primary caregiver team members if providing Wraparound services)
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Youth served
  • Review case records


CA-YPS 3.01

The rehabilitation team, with input from the youth and primary caregiver, coordinates services with specialty mental health, substance use treatment, education, child protection, primary health care, and juvenile justice, as appropriate.


If the organization does not provide any of the services listed above, such as may be the case for Wraparound programs, then it must formally document how those youth’s needs are being met. If the services are not necessary for the youth (e.g., they are not involved with juvenile justice at all), it should be documented that the youth was assessed for those needs and it was determined unnecessary.


CA-YPS 3.02

A lead worker serves as the primary point of contact for the youth and family/primary caregiver in the service planning process to:
  1. perform a strengths-based assessment;
  2. conduct plan-of-care meeting;
  3. help to determine needs and resources;
  4. arrange for provision of specific services; and
  5. monitor implementation of the service plan.
Examples: A point of contact may have a different title from organization to organization, for example wraparound programs would refer to this individual as the care coordinator.


CA-YPS 3.03

The wraparound care coordination team includes a care coordinator, personnel providing services from each sector, the child and family team, a mobile crisis team, and a provider network.
NA The organization does not provide wraparound services.
Examples: The child and family team may consist of the youth and, in addition to the primary caregiver, all adults and family members that play a positive role in the youth’s life as well as provide natural community support. Child and family teams can also include a family support partner (also referred to as a family support specialist) who is a parent who has had similar experiences with their own family and as a result has an understanding of the various systems and is able to provide support to the other adults to help them find their voice.


CA-YPS 3.04

Prior to a crisis situation, youth and their primary caregivers are informed about how to access the mobile crisis team, which includes psychologists and social workers trained in crisis intervention, when the care coordinator is not available.


When permitted by local or provincial regulation, the organization may contract with a third party, such as a community crisis hotline, to provide crisis assistance.
NA The organization does not provide wraparound services.
Examples: A mobile crisis team may be of use when the care coordinator is not available to review a potential inpatient psychiatric hospitalization of a youth.


CA-YPS 3.05

The organization creates a provider network by cultivating a relationship with an array of service providers to help support the youth and family/primary caregiver’s needs.