Standards for public agencies

2020 Edition

Youth Psychosocial Services (PA-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.
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.
Examples: Service sectors frequently accessed by youth include: specialty mental health, substance use treatment, education, child welfare, general medicine, and juvenile justice.
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
  • Service planning and monitoring procedures
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Youth served
  • Review case records

PA-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 agency 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.

PA-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

PA-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 behavior and identify steps to take in the event of a crisis.

PA-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.

PA-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.