Standards for public agencies

2020 Edition

Youth Psychosocial Services (PA-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.
2020 Edition




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.
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
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

PA-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 welfare, primary health care, and juvenile justice, as appropriate.


If the agency 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.

PA-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 agency to agency, for example wraparound programs would refer to this individual as the care coordinator.

PA-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 agency 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.

PA-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 state regulation, the organization may contract with a third party, such as a community crisis hotline, to provide crisis assistance.
NA The agency 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.

PA-YPS 3.05

The agency 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.