2022 Edition

Youth Psychosocial Services (CA-YPS) 5: Service Planning and Monitoring

Youth participate in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and 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.
Examples: Service sectors frequently accessed by youth include: specialty mental health, substance use treatment, education, child protection, general medicine, and juvenile justice.
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
  • In a few instances, client or staff signatures are missing and/or not dated; or
  • With few exceptions, staff work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc.; 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
  • In several instances, client or staff signatures are missing and/or not dated; or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is clearly inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or  
  • Documentation is routinely incomplete and/or missing; or
  • Individual staff members work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc., but this is the exception.
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
  • Service planning and monitoring procedures
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Youth served
  • Review case records


CA-YPS 5.01

An assessment-based service plan is developed in a timely manner with the full participation of the youth and their family/primary caregiver, and includes:
  1. agreed upon goals, desired outcomes, and timeframes for achieving them;
  2. services and supports to be provided, and by whom; 
  3. possibilities for maintaining and strengthening family relationships and other informal social networks; 
  4. procedures for expedited service planning when crisis or urgent need is identified; and
  5. the youth’s signature.


If the youth has been identified as a victim of human trafficking, the organization should work with the youth and their primary caregiver to develop a safety plan that focuses on increasing physical safety by securing needed documents, property, and services and linking efficiently to law enforcement, if needed.


Noting experiences with family rejection and opportunities for increasing family acceptance and support should be part of the assessment for family relationships and the service plan should include culturally appropriate education and guidance to help families with LGBTQ youth decrease family rejection and increase family support.


CA-YPS 5.02

The service plan addresses, as appropriate:
  1. unmet service and support needs;
  2. psychological and emotional needs;
  3. educational goals;
  4. cultural interests;
  5. development of life skills, including preparation to work or continuation of schooling; and
  6. improvement in the person’s quality of life and necessary skills to remain within the community.

Fundamental Practice

CA-YPS 5.03

Youth and their primary caregivers work with the service provider to create a crisis or safety management plan that addresses ways to prevent escalation of youth’s behaviour and identify steps to take in the event of a crisis.


CA-YPS 5.04

The worker and a supervisor, or a clinical, service, or peer team, review the service plan quarterly, or more frequently depending on the needs of youth, to assess:
  1. service plan implementation;
  2. progress toward achieving service goals and desired outcomes; and
  3. the continuing appropriateness of the service goals.


When experienced workers are conducting reviews of their own cases, the worker’s supervisor must review a sample of the worker’s evaluations as per the requirements of the standard.


CA-YPS 5.05

The worker, youth, and his or her family/primary caregiver:
  1. review progress toward achievement of agreed upon service goals; and 
  2. sign revisions to service goals and plans.