Our Brothers’ Keepers of Southern Illinois (OBK)

Action Plan
Client Name: Last Update Date:
Summary Review Plan (Dates Scheduled / Actual)
90 Day: 6 Month: 9 Month: 12 Month:

Goals/Needs (Copy from RON) Plan/Actions/Notes (Copy from RON) Target Date Current Status Goal Status
Urgent N – New
Continuing C – Continuing
Discontinue A – Achieved
Achieved D - Discontinue
Social Security: 90 Day:
6 Mon:
9 Mon:
12 Mon:

Social Security Disability: 90 Day:

6 Mon:
9 Mon:
12 Mon:
Legal: 90 Day:
6 Mon:
9 Mon:
12 Mon:
Clothing/Personal Care: 90 Day:
6 Mon:
9 Mon:
12 Mon:

Education: 90 Day:
6 Mon:
9 Mon:
12 Mon:

OBK Rev 3/11/2021

 Our Brothers’ Keepers of Southern Illinois (OBK)
Action Plan
Client Name:

Goals/Needs (Copy from RON) Plan/Actions/Notes (Copy from RON) Target Date Current Status Goal Status
Urgent N – New
Continuing C – Continuing
Discontinue A – Achieved
Achieved D - Discontinue
Employment: 90 Day:
6 Mon:
9 Mon:
12 Mon:
Financial Assistance: 90 Day:
6 Mon:
9 Mon:
12 Mon:
Food: 90 Day:
6 Mon:
9 Mon:
12 Mon:
Health Screening: 90 Day:
6 Mon:
9 Mon:
12 Mon:
Housing: 90 Day:
6 Mon:
9 Mon:
12 Mon:
Identification: 90 Day:
6 Mon:
9 Mon:
12 Mon:

OBK Rev 3/11/2021

 Our Brothers’ Keepers of Southern Illinois (OBK)
Action Plan
Client Name:

Goals/Needs (Copy from RON) Plan/Actions/Notes (Copy from RON) Target Date Current Status Goal Status
Urgent N – New
Continuing C – Continuing
Discontinue A – Achieved
Achieved D - Discontinue
Mental Health: 90 Day:
6 Mon:
9 Mon:
12 Mon:
Mentoring: 90 Day:
6 Mon:
9 Mon:
12 Mon:
Substance Abuse: 90 Day:
6 Mon:
9 Mon:
12 Mon:
Transportation: 90 Day:
6 Mon:
9 Mon:
12 Mon:
Other Needs: 90 Day:
6 Mon:
9 Mon:
12 Mon:
Other Goals: 90 Day:
6 Mon:
9 Mon:
12 Mon:

OBK Rev 3/11/2021

 Our Brothers’ Keepers of Southern Illinois (OBK)
Action Plan
Client Name:
We agree to carry out the responsibilities outlined in this Action Plan to the best of our ability:

___________________________________________________________
Please sign and date: Staff Signature Date

____________________________________________________ ___________________________________________________________
Client/Representative Date Supervisor’s Signature Date

___________________________________________________________________________________________________________________________________

90 Day Review:
___________________________________________________________
Please sign and date: Staff Signature Date

____________________________________________________ ___________________________________________________________
Client/Representative Date Supervisor’s Signature Date

___________________________________________________________________________________________________________________________________

6 Month Review:
___________________________________________________________
Please sign and date: Staff Signature Date

____________________________________________________ ___________________________________________________________
Client/Representative Date Supervisor’s Signature Date

___________________________________________________________________________________________________________________________________

OBK Rev 3/11/2021

 Our Brothers’ Keepers of Southern Illinois (OBK)
Action Plan

Client Name:

9 Month Review:
___________________________________________________________
Please sign and date: Staff Signature Date

____________________________________________________ ___________________________________________________________
Client/Representative Date Supervisor’s Signature Date

___________________________________________________________________________________________________________________________________

12 Month Review:
___________________________________________________________
Please sign and date: Staff Signature Date

____________________________________________________ ___________________________________________________________
Client/Representative Date Supervisor’s Signature Date

___________________________________________________________________________________________________________________________________

OBK Rev 3/11/2021