CSSP/ISP Addendum, Residential Services

Residence:

Meeting Date:

Next Meeting Information

Date: ______, Time: ______

Location: ______

Type of Meeting: ______

1 (Annual, Semi-Annual)

Descriptive Information

Client Name: Meeting Date: Date of Birth: Date Report Emailed to Team: Date of Admission: Indicate if the report was sent by another method: County of Residence: County of Financial Responsibility:

Financial Information

Client Funds Is there a Burial Fund? Yes or No Cash: If yes, location:

Checking: Is there a Special Needs Yes or No Trust? Savings: If yes, who oversees the trust? Other Assets Yes or No (i.e. savings bonds) Representative Payee: If yes, information regarding those assets: Able to manage their finances? Independently With Some Assistance Needs Complete Support Comments:

Team Contact Information

Type of Contact Name Address and Email Phone Emergency: Legal Representative: Case Manager: Financial Worker: Residential Manager: Vocational Manager: Day Treatment Program:

Individual can have unsupervised contact with the following persons:

Health Needs

Diagnosis (According to most recent psychological assessment or other materials as available):

Allergies: Yes No If yes, list allergies:

Seizure Disorder: Yes No

Difficulties with Choking: Yes No If yes, explain support required:

Special Dietary Needs:

Current Weight:

Ability to Self-Manage Health Needs indicated above or supports required:

Overall Strengths in the area of Health Needs:

Health Care Providers Type of Provider Name Address/Email/Phone Appointment Additional Supports Provided Frequency Primary Physician: Dentist: Psychiatrist/CNP: Psychologist – Group: Psychologist – Individual:

Monitoring Health Conditions Health Condition Written Instructions for Monitoring the Procedures to Follow to Meet These Health Condition from Licensed Health Instructions Professional (and location of those instructions)

Medical Equipment, Devices, Aids, Technology Used Type of Equipment or Device Used Written Instructions for Monitoring the Procedures to Follow to Meet These Health Condition from Licensed Health Instructions Professional (and location of those instructions)

3 Review of Assessments and Evaluations Type Date of Last Assessment Date of Next Assessment Annual Physical Dental Vision Hearing Psychiatry Psychological Group: Group: Individual: Individual: Neurology Endocrinology Last Psychological Evaluation: Date: Tests Administered: Completed By: IQ and Summary:

Medications

Scheduled Medication/Dose Check if Indications Purpose Psycho- tropic

PRN Medications Check if Indications Purpose Psycho- tropic

* Indicates a change to this medication during this reporting period

Notifies staff of Independently With Some Assistance Needs Complete Support medical/dental needs? Comments: Schedules health care Independently With Some Assistance Needs Complete Support appointments? Comments: Preventative Health Screening

4 Required? Support required with preventative health screenings: Level of Support Provided with Medication Set Up: Medication Administration: Meaning the arranging or set up of medication for later administration Medication Assistance: Meaning bringing previously set up medications to the person, bringing them food or drink to accompany their medications, or providing reminders to the person to take regularly scheduled medication or perform regularly scheduled treatments and exercises. Medication Administration: Meaning the staff are fully responsible for all aspects of medication administration. Comments: Instances of Medication No Refusal or Failure to Take Yes; If yes, explain: Medications as Prescribed:

Summary of Appointments

General Medical:

Psychiatry:

Dental:

Other:

Basic Needs

Able to obtain food, clothing Independently With Some Assistance Needs Complete Support and shelter? Comments:

Safety Needs

At risk of falling? Yes No If yes, supports required: Mobility limitations? Yes No If yes, supports required: Ability to regulate water Yes No If no, supports required: temperature? Adequate community survival Yes No If no, supports required: skills (pedestrian safety, stranger 5 awareness, etc.)? Has water safety skills? Yes No If no, supports required: Has sensory disabilities? Yes No If yes, please explain ability to self-manage or supports required: Overall Strengths in the area of Safety Needs:

Social Skills and Relationships

Relationship with Peers: Other Meaningful Relationships:

Communication Skills

Communication Assessment: Community Meeting Participation: Comments:

Home Living Skills Maintains Clean living area and bedroom? Independently With Cues Significant Support Needed Completes Household Chores? Independently With Cues Significant Support Needed Completes Laundry? Independently With Cues Significant Support Needed Assists with Cooking? Independently With Cues Significant Support Needed Comments:

Self Care

Is the client able to complete all self care tasks Independently With Cues Frequent Refusal (Eating, toileting, bathing, etc.)? Comments:

Recreation and Leisure

Summary of Recreational Preferences and Opportunities:

Symptomatic/Behavioral Needs

Target Behavior # of Occurrences # of Occurrences (Current Reporting Period) (Previous Reporting Period) #1: #2: #3: #4: #5: #6: Comments: Ability to self-manage symptoms or target behaviors: Overall Strengths in this area:

6 Supports required:

Vocational

Vocational Summary: Attendance:

7 Summary of Outcomes

Report Period Covered:

Goal #1: Achievement Criteria: Summary of Data: Person was successful in achievement of Goal #1 % of the time. Previous Reporting Period Percentage: % Recommendation: Continue Revise Discontinue Rationale for Recommendation:

8 Outcomes – Supports and Methods

Goal #1: Person Centered Outcome:

Criteria of Achievement: Methods – Goal #1 Outcome Development Date: Outcome Projected Implementation Date: Describe where and when this program will be run: (include social and physical environments):

Identify the reinforcers to be used:

Identify needed equipment and materials:

Describe how data is to be collected and charted, including how often:

Specific interventions to be used consistent with communication mode:

Specific interventions to be used consistent with learning style:

Names of staff or positions responsible for implementation:

These supports will be reviewed on an ( Annual Semi-annual) basis.

9 Goal #2: Person Centered Outcome:

12 Attendance

All team members in attendance will sign, identify their title or role, and indicate the date they attended. Signature below also indicates plan approval. Signature Title Date

Justify why the Legal Representative or Client did not attend if one or both did not: