Participates in the development of a written comprehensive individualized treatment plan that is based on the assessment of the individual s clinical needs; determines need for services and ensures that referrals for ancillary, support and consultative services are noted and made; reviews and updates individual treatment plan according to all applicable guidelines and in response to clinical change; and ensures that arrangements are made and documented for continuation of care well in advance of individual s planned departure. As an integral member of the treatment team, ensures that all relevant clinicians are kept informed of the individual’s clinical needs, family social adjustment, services needed and their availability through clear documentation of the record.