Page 1.
Residential
Movement Sheet
Name: ____________________________________________
Benefits Received: ___________________________________
Sex: __________________
Guardian: Rep. Payee: _______________________________________
Dob: _________________________
Medicare#: ___________________________________________
Medicaid #: ___________________________________________
Tel:_________________________
SS # ________________________
Moving from:________________________________________________________
Moving to: (include
phone #) ___________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
________________________________________________
How Long at Above Address: _____________
Date of Move:_______________________
CM Involved:__________________________________________
CM
Involed:__________________________________________
Program/Job:_________________________________________
Projected Program/Job:_________________________________
Reason for Move:________________________________________________________
I. Most Recent Diagnosis:__________________
Date of Most Recent Plan:(include Plan)_______________________
Critical Areas Required Immediate Attention
A. Family Physician: ___________________
Tel:______________
1. Medial problems (describe briefly) ________________________________________________
B. Medication: _______________________________
C. Allergies: ______________________________
2. Behavioral Problems (describe briefly) ______________________________________________
D. Seizures: _____________________________________________________
E. Diet: Special Conderation: ___________________________________
II. Physician/Sensory Handicaps
III. Adaptive Equipment
Normal
A. Vision _______________
B. Hearing ______________
C. Ambulation __________
Impaired
A. Hearing Aid _____________
B. Glasses ________________
C. Braces _________________
D. Splints _________________
E. Walker ________________
F. Wheelchair _____________
D. Communication __ Verbal __ Signing __ Augmentative/Communication Device __ Gestures__ Expressive/Receptive __
Page 2.
IV. Daily Living Skills: (make a (x) after each statement that accurately describes the applicant's situation)
A. Eating
1. Utensils: Spoon___ Fork____ Knife_____ Adaptive
Equipment_____
2. Skills:
Needs to be fed _____
served _____
Supervised (choking) _____
Able to serve self appropriately and eat a "normal" pace _______
Able to participate in food preparation _______
B. Toileting
1. Incontinent of bowel and bladder _______
2. Incontinent of bladder only _______
3. Occasional ccidents_______
4. Wears diapers, if so when _______
5. Schedule training _______
6. Will indicate toilet needs to staff _______
7. Uses the bathroom independently; needs refinement _______
8. Attends to toileting needs independently including washing hands _______
C. Dressing
1. Requires hand over hand assistance _______
2. Able to undress _______
3. Able to put on articles of clothing, but requires staff prompting and assistance; _______
4. Staff assistance necessary for buttoning, tying, zipping, etc _______
5. Dresses independently, needs staff assistance for appropriate clothes selection _______
6. Selects coordinated outfits including outerwear appropriate for the weather _______
Page 3.
D. Washing/Bathing
1. Needs hand over hand staff assistance _______
2. Washes incompletely, requires staff direction to wash all areas _______
3. Staff needs to provide verbal prompts and guidance; give soap and washcloth _______
4. Staff need to draw water, but consumer can bathe independently _______
5. Able to carry out bathing, drying, etc. independently _______
E. Hair care
1. Requires staff to wash, rinse, and comb/brush hair _______
2. Needs help in applying shampoo and rinsing; requires only "touch-up" combing _______
3. Is able to wash and rinse hair with verbal prompts only; brushes independently _______
4. Independently in all areas of hair care _______
F. Tooth brushing
1. Needs to have teeth brushed by staff _______
2. Hands-over-hand assistance is required in tooth brushing ;_______
3. Applies toothpaste, but requires staff to cues to brush thoroughly _______
4. Applies toothpaste and brushes teeth completely independently _______
G. Sleeping
1. Wakes frequently during the night _______
2. Has nightmares _______
3. May get up and wander during the night _______
4. Wakes rarely or occasionally to use the bathroom _______
5. Sleeps throughout the night _______
Page 4.
V. Social Skills
1. Interacts with staff only ______
2. Interacts with peers ______
3. Enjoys social activity ______
4. Enjoys going out into the community ______
5. Dislikes being around groups of people, crowds ______
VI. Miscellaneous
1. Able to follow simple directions (yes) ______ (no) ______
2. Able to go outside and knows the way around (yes) ______ (no) ______
3. Any difficulty in mobility (specify) (yes) ______ (no) ______
4. Able to care for self during menstruation (yes) ______ (no) ______
5. Awareness of time in relation to daily activities (yes) ______ (no) ______
VII. Personal Identifying Information
Interested and Involved Family/Others ___________________________________
Religious Preference _________________________________________________
Likes/Motivators (Special activities, personal belongings, friends): _________________________________________________________
Dislikes (activities, sensory stimulation, etc.): _______________________________________________________________________
Page 5.
VIII. Previous Placement Information
If placement has terminated due to problem behaviors, please answer the following:
1. Description of Behaviors(s)
2. Duration of Behavior Issues (6 mo/10yrs)
3. Frequency (Once a day or twice a wk)
4. Antecedents (Events preceding)
5. Consequences (events following behavior)
6. Person Involved Resolving the (psychologist/family)
1. ___________________________________________________________________________________________
2. ___________________________________________________________________________________________
3. ___________________________________________________________________________________________
4. ___________________________________________________________________________________________
5. ___________________________________________________________________________________________
6. ___________________________________________________________________________________________
7. ___________________________________________________________________________________________
Example:
___________________________________________________________________________________________
Kicking other 2 years Once
a day Someone changes Ask
consumer to Boarding
consumers T.V.
station apologize,
then home
with foot leave
room until operator
calm
___________________________________________________________________________________________ |
