Status Check

Status Check

Non supported Living Consumers
Use this form if you work with an individual who does not receive supported living services from the provider to determine the health, safety, and well-being of the client and to identify any observed issues and to describe resolutions to these issues. Complete this form on Intake and Quarterly.
Consumer Name:

First NameLast Name
Consumer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Service Provided:
Individual Living Arrangements (select all that apply)
Does Individual have a guardian?
Name of Guardian if Applicable?
Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does another supported living agency provide services to the individual?
If yes, Agency Name
SLC Name:
Is there any issue regarding what the client/guardian expects from the provider and what the provider can actually provide? (Describe)
Health concerns ? Yes/No (Describe if applicable)
Safety concerns? Yes/No (Describe if applicable)
Medication Concerns? Yes/No (Describe if applicable)
Behavioral Concerns? Yes/No (Describe if applicable)
Home Maintanence Concerns? Yes/No (Describe if applicable)
Consumer Signature:
Guardian Signature:
Staff Signature:
Date Completed:

MonthDayYear
Date
Should be Empty: