Page 358

Low Income Home Energy Assistance Program Division 10 Service 415 Program 415 Chapters 05 - 65 North Dakota Department of Health and Human Services

year around monthly payment plan. The worker can write in the phone numbers and/or addresses of the referred agencies or the appointment dates if the worker helps set up the first appointment.

The Action Plan will be most effective for the cooperative customer who wants to make improvements. However, it may also be used with the more reluctant customer who may not have given much thought to the reasons for his repeated crises.

When a customer is uncooperative or has few skills, it is especially important to set small goals. If he/she is overwhelmed by too much at once, he/she is more likely to do nothing.

The "Action Plan" cannot be used as a referral form, because it may contain more information than the referred agency needs, especially if multiple problems are identified. The actual referrals to agencies identified in the Action Plan should be made by separate letters. The Release of Information may be completed by the worker by filling in the agency name (CIRCLE either Energy Share or County Social Services, as appropriate) and the customer name.

Signature The customer and worker both sign and date the "Action Plan."

Distribution The customer receives the original copy and the yellow copy goes to the agency case file.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms.