Conducts comprehensive assessments and on going re assessments of the client including psychosocial, physical and mental health, environmental and spiritual needs. Develops and initiates a care plan, which is client centered, comprehensive and consistent with program guidelines and policies and procedures; modifies care plan as client's care needs change. Conducts home vi

Determines participant needs including psychosocial, physical and mental health, financial, and environmental issues by completing in depth psychosocial assessment. Based on findings developes and initiates a participant centered service plan consistent with program guidelines. Cultivates relationships and partnerships with community providers that support and extend soci