This form is designed to help facilitate understanding of the family’s circumstances, knowledge of sickle cell disease, and satisfaction with health care and to identify patient and family concerns and potential barriers to appropriate treatment. It should be completed by the family when the child is not ill (e.g. in the waiting room prior to a clinic visit) and subsequently reviewed with the family by a health care provider. Print this form, complete it and give to your provider.
This document should be shared with the youth and parent/caregiver . Attach the immunization record to this form
This 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. Information from the transition readiness assessment can be used to develop goals. The plan of care should be updated often and sent to the new adult clinician as part of the transfer package.