DAILY SERVICE NOTE
Provider’s Name: Personal Touch Professional Services Il Individual Name: Jack Weckerly DOB: 10/16/1975 MCI: 002790492 W Code (s): W5996 Service Location Address: 6603 N Gratz St, Philadelphia, 19126 Service Delivered: CPS Unit of Service: 15min
Date of Service:
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Month
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Day
Year
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Please indicate the hours worked:
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8am-12pm
12pm-4pm
Other
Other: If hours worked are different from hours listed above. Please document here
Type of Activities: Please select all that apply:
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Promoting a spirit of personal reliance and contribution to the community
Developing mutual support and community connection
Developing social networks and connections within local communities
Planning and coordinating of the daily/weekly schedule for CPS with the individual
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Outcome Phase: Community Integration
Goal: Jack will participate in a community outing of his choice at least once a week as he tolerates. Please select all that apply:
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Community Walk
Community Store
Community Center/Park
Barbershop
Mall
Restaurant
Shopping
Volunteer
Religious Institution
Movies
Bowling
Gym
Visited Family Member or Friend
Other
Please indicate whether the Goal was Completed/Not Completed:
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Rows
Yes
No
Goal Completed
If the goal was not completed today, explain why:
Was transportation provided to the outing?
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Yes
No
If your answer is "No," please explain the reason below:
Provide a summary of the shift also document any issues or appointments below: Also note if the goal was completed along with supports given and progress. If not completed, explain why.
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List barriers & conditions necessary for community inclusion. Please Select all that apply:
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Unable to express needs adequately
Low Motivation
Communication Barrrier
Other
Strengths & Skills: Please Select all that apply.
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Self- motivated
Good Leadership skills
Able to express needs
Able to follow directions
Easy to make friends
Other
DSP Printed Name:
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Date:
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Signature
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