<p> QUALITY OF LIFE DAY PLAN ASSESSMENT PRE PLANNING FOR PERSON CENTERED PLANNING MEETING FOR RESIDENTIAL CARE Consumer Name (First, MI, Last) Consumer No.</p><p>Consumer is non-verbal Pre-Plan Date: How was input obtained during pre-planning meeting? PCP Meeting Date: </p><p>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? </p><p>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? </p><p>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? </p><p>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: </p><p>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?</p><p>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:</p><p>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: </p><p>Bathing/Toileting</p><p>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.</p><p>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: </p><p>Grooming/Hair Care I like to wash my hair at this time: On these days: </p><p>I like to do my grooming activities at these times: Other things about grooming that is important to me: </p><p>Oral Care I like to do my oral care activities at these times: Other things that are important to me about oral care activities: </p><p>Clothing/Dressing I like to dress at this time: I like to prepare for bed at night by changing at this time:</p><p>Other things about Clothing/Dressing that are important to me: </p><p>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 </p><p>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? </p><p>Signatures of those that participated in Pre Planning</p><p>Signature Date Signature Date</p><p>Signature Date Signature Date</p><p>Signature Date Signature Date</p><p>PRE PLANNING FOR PERSON CENTERED PLANNING MEETING FOR CLS, PC AND SKILL BUILDING SERVICES Page 3 Rev. 7/2010</p>