Choices and Goals Report

CHOICES AND GOALS REPORT Provider’s Signature ______RECIPIENT’S NAME (CT) ______MONTH______YEAR ______SERVICE ______Goals: 1. 3.

Date: ______Date: ______What activity was worked on? ______What activity was worked on? ______What goal was the activity related to? 1 2 3 4 (circle one) If not related, what was the What goal was the activity related to? 1 2 3 4 (circle one) If not related, what was the purpose of the activity? ______purpose of the activity? ______What choices were offered to the CT? ______What choices were offered to the CT? ______What preferences were made by the CT? ______What preferences were made by the CT? ______

Date: ______Date: ______What activity was worked on? ______What activity was worked on? ______What goal was the activity related to? 1 2 3 4 (circle one) If not related, what was the What goal was the activity related to? 1 2 3 4 (circle one) If not related, what was the purpose of the activity? ______purpose of the activity? ______. ______. What choices were offered to the CT? ______What choices were offered to the CT? ______What preferences were made by the CT? ______What preferences were made by the CT? ______Date: ______Date: ______What activity was worked on? ______What activity was worked on? ______What goal was the activity related to? 1 2 3 4 (circle one) If not related, what was the What goal was the activity related to? 1 2 3 4 (circle one) If not related, what was the purpose of the activity? ______purpose of the activity? ______. ______. What choices were offered to the CT? ______What choices were offered to the CT? ______What preferences were made by the CT? ______What preferences were made by the CT? ______

Date: ______Date: ______What activity was worked on? ______What activity was worked on? ______What goal was the activity related to? 1 2 3 4 (circle one) If not related, what was the What goal was the activity related to? 1 2 3 4 (circle one) If not related, what was the purpose of the activity? ______purpose of the activity? ______. ______. What choices were offered to the CT? ______What choices were offered to the CT? ______What preferences were made by the CT? ______What preferences were made by the CT? ______

All About Behavior, LLC 410 SE 11th Street, Ocala, FL 34471 ph. 352-368-2655 fax 352-629-6806 All About Behavior, LLC 410 SE 11th Street, Ocala, FL 34471 ph. 352-368-2655 fax 352-629-6806