4.5 In collaboration with youth (and their family members/caregivers, if appropriate), complete an individualized transition plan and keep it up-to-date.

An individualized transition plan outlines the specific transition goals, support needs and actions required to help youth transition into adult mental health services. It acts as a reference for navigators and clinicians to support youth through the transition process and ensure their needs are met (see Component 3.3). Developing an individualized transition plan requires strong collaboration with youth and they should be made aware of the transition plan as they undergo changes in the care they receive. As youth progress through the transition process, it is important to update the transition plan.

The transition plan might include:

1. Transition goals and prioritized actions
2. Readiness assessment: A process of determining if youth are prepared to begin the transition process into adult mental health services.
3. Clinical Summary: A summation of pertinent patient information that can be used to convey the condition and journey of a patient, including relevant diagnoses or problems, treatments, medication history and important contact information.
4. Crisis plan: A predetermined plan that outlines means of support for youth who may experience a mental health crisis.

Given the challenges that may arise during the transition process, it is important to include a crisis plan as a part of the transition plan. A crisis plan represents a predetermined set of steps that can be taken to support an individual through a mental health crisis. It outlines helpful, specific information, including warning signs, coping strategies, emergency contacts, and supports, as well as interventions to help the individual feel safe. Should youth find themselves in between transitions without access to resources, a crisis plan can be helpful to determine where they can access services.