QUALITY OF LIFE DAY PLAN ASSESSMENT PRE PLANNING FOR PERSON CENTERED PLANNING MEETING FOR RESIDENTIAL CARE Consumer Name (First, MI, Last) Consumer No.

Consumer is non-verbal Pre-Plan Date: How was input obtained during pre-planning meeting? PCP Meeting Date:

1. Do you have a legal guardian? No Yes If yes, what is their scope of authority (Full/Limited)? If limited, please specify. Please comment on involvement with pre-planning. How will the guardian be involved in the Person Centered Planning Meeting?

2. Are there any special accommodations that need to be made for you or your support persons? (I.e. cultural, spiritual, physical, age, gender, sexual orientation, non-verbal communication, language, socioeconomic status, etc.) No Yes If yes, how can we make sure your needs are met for the Person Centered Planning Meeting?

3. Do you have any religious or cultural factors that may effect your treatment? No Yes If yes, how would you like these addressed at the Person Centered Planning Meeting?

4. Do you need assistance with any other resources before we create your treatment plan at your person centered planning meeting? No Yes If yes, please explain:

5. What is the best way for us to know if you are happy with what is being talked about at your person centered planning meeting?

6. DAY PLANNING To help me achieve my hopes, dreams and desires, I prefer my Week Day / Weekend to be structured as noted below: Nutrition I like to eat at these times: Breakfast: ______Lunch: ______Dinner: ______I Like to eat/Drink the following foods: I do not like to eat/drink the following:

Sleeping I like to go to bed at this time: I like to get up at this time: I like to take naps at this time: Other things about sleeping that is important to me:

Bathing/Toileting

PRE PLANNING FOR PERSON CENTERED PLANNING MEETING FOR CLS, PC AND SKILL BUILDING SERVICES Page 1 Rev. 7/2010 QUALITY OF LIFE DAY PLAN ASSESSMENT PRE PLANNING FOR PERSON CENTERED PLANNING MEETING FOR RESIDENTIAL CARE Consumer Name (First, MI, Last) Consumer No.

I like to take a Bath Shower at this time of day: On these days: Other things about bathing/toileting that are important to me:

Grooming/Hair Care I like to wash my hair at this time: On these days:

I like to do my grooming activities at these times: Other things about grooming that is important to me:

Oral Care I like to do my oral care activities at these times: Other things that are important to me about oral care activities:

Clothing/Dressing I like to dress at this time: I like to prepare for bed at night by changing at this time:

Other things about Clothing/Dressing that are important to me:

Community Integration I like to participate in the following types of I like to participate in these activities at the community integration activities: following times: a.m. p.m. both a.m. & p.m. other: Leisure I like to participate in the following types of Leisure I like to participate in these activities at the activities: following times: a.m. p.m. both a.m. & p.m. other: Meaningful Activities The following types of activities are meaningful to I like to participate in these activities at the

PRE PLANNING FOR PERSON CENTERED PLANNING MEETING FOR CLS, PC AND SKILL BUILDING SERVICES Page 2 Rev. 7/2010 QUALITY OF LIFE DAY PLAN ASSESSMENT PRE PLANNING FOR PERSON CENTERED PLANNING MEETING FOR RESIDENTIAL CARE Consumer Name (First, MI, Last) Consumer No. me (school, work, volunteer, participate on a following times: team): a.m. p.m. both a.m. & p.m. other: 7. If you have questions or change your mind about anything, who would you like to talk to?

Signatures of those that participated in Pre Planning

Signature Date Signature Date

Signature Date Signature Date

Signature Date Signature Date

PRE PLANNING FOR PERSON CENTERED PLANNING MEETING FOR CLS, PC AND SKILL BUILDING SERVICES Page 3 Rev. 7/2010