SHOULDERS HOUSE CASE NOTES
(ACHIEVING BETTER COPING SKILLS, LLC)
Youth Name
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First Name
Last Name
Staff Name
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First Name
Last Name
Date
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Month
-
Day
Year
Date
Shift Time
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CLIENT INFORMATION
Youth Status
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Youth Status Changed notes (If applicable)
Case Note Rating
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Neutral
Positive
Negative
School Related
Appointment Related
Check ONLY that apply
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Youth mood was positive
Youth mood was negative
Youth mood was stable
Youth was away on pass
Youth completed all chores
Youth completed a portion of his chores
Youth did not complete chores
Youth completed homework
Youth did not complete homework
Youth hygiene is healthy
Youth hygiene needs improvement
Youth interacted with peers positively
Youth interacted with peers negatively
Youth did not interact with peers
Youth played games
Youth watched TV
Youth cooked today for ILT Program
Youth stayed in room
Youth took his medication
Youth refused some or all of his medication
Youth tested positive for Drug Test
Youth tested negative for Drug Test
Youth arrived on time from pass or school
Youth arrived late from pass or school
Youth house status increased
Youth house status dropped
Youth put on full restriction
School Related - See additional notes
Appointment Related - See additional note
Additoinal notes should be used for further explaination of Positive or Negative case notes
Additional Notes
Staff Signature
*
Submit
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