Community Participation Support Note
Client Name
*
First Name
Last Name
Hub Location
Where did you meet the client?
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Time
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Day
Year
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Minutes
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PM
AM/PM Option
End Time
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PM
AM/PM Option
Type of Interaction
*
Please Select
Community Paticipation Supports
Describe what the client is wearing:
*
ISP Goals addressed
Financial Literacy - Complete a financial transaction
Socialization - Engage in appropriate social interactions
Literacy - Ability to read and write
Community Engagement - Able to activley participate in a community acitivity
Healthy Eating - Able to make healthy food choices independently
Emotional Regulation - Able to effectively manage emotions in the community
Stress Management - Able to appropriately manage stressful situations (using coping skills, additional supports, therapeutic techniques)
Communication - Able to appropriately communicate needs and wants
Relationship Building - Able to establish and maintain appropriate healthy relationships in the community.
Exercise - Able to engage in a physical activity (karate, dancing, gym, going for a walk, etc)
Client Assessment
Mood
*
Please Select
Happy
Depressed
Anxious
Angry
Stable
Interpersonal
*
Please Select
Interactive
Guarded
Withdrawn
Hostile
Functional Status
*
Please Select
Intact
Impaired
Progressing
Digressing
Variably Impaired
Community Engagement
1. Did the client experience any challenges or difficulties during their community participation?
*
Yes
No
2. Did the client express any discomfort or unease in social settings within the community?
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Yes
No
3. Did the client encounter any barriers or obstacles that hindered their community integration?
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Yes
No
4. Did the client require additional support or assistance to navigate social interactions in the community?
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Yes
No
5. Did the client encounter any instances of misunderstanding or lack of acceptance from community members?
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Yes
No
6. Did the client exhibit signs of anxiety or distress during their community interactions?
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Yes
No
7. Did the client have any difficulty expressing themselves to familiar or unfamiliar people in the community?
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Yes
No
8. Did the client require additional guidance or instruction on appropriate behavior in different community settings?
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Yes
No
9. Did the client face any challenges in accessing community resources or participating in community events?
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Yes
No
10. Did the client require any specific accommodations or modifications to facilitate their community participation?
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Yes
No
Community Engagement Explained
*
DSP Involvement
1. Did you actively facilitate opportunities for the client to participate in community events or activities?
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Yes
No
2. Have you supported the client in joining community organizations or groups?
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Yes
No
3. Did you provide guidance on appropriate social behavior and interaction in community settings?
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Yes
No
4. Were you involved in helping the client establish and maintain relationships with community members?
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Yes
No
5. Did you assist the client in accessing community resources or services?
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Yes
No
6. Have you witness instances where the client actively engaged with community members?
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Yes
No
7. Did you receive any positive feedback from community members regarding clients' interactions?
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Yes
No
8. Were you involved in arranging or supervising volunteer activities for the client within the community?
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Yes
No
9. Did you provide support to the client in navigating community spaces or public transportation?
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Yes
No
10. Have you helped the client develop strategies to overcome challenges or obstacles they may face when interacting in the community?
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Yes
No
Community Activity location(s)
*
Safety & Medical Issues
Safety Issues
*
Suicidal Ideation
Homicidal Ideation
None
Self Injurious Behavior
Verbal Aggression Towards Others
Physical Aggression Towards Others
Property Destruction
Other
Client has
*
Intent to act
Plan to act
Means to act
None
Subjective / Objective
Subjective Report (what the client says)
*
Feels depressed
Feeling anxious
Anxiety decreasing
Lack of motivation
Sleeping too little
Sleeping too much
Feels overwhelmed
Feels directionless
Feels stressed
Feels worse overall
Feels better overall
Maintaining progress
Communication worse
Communication same
Feeling grief and loss
Feels self-conscious
Anger issues
Mood swings stable
Mood swings worse
Mood swings better
Lack of focus/organiz.
Increased Socialization
Getting more exercise
Feels more secure
More self-confident
Increase in motivation
Better self-care (ADLs)
Other
Observations (what you see)
*
Seems depressed
Seems anxious
Lack of motivation
Sleeping too much
Seems overwhelmed
Seems better overall
Seems worse overall
Seems stressed
Communicat. improved
Aggressive
Decreased Aggression
Communication decreased
Maintaining progress
Mood swings better
Mood swings worse
Anxiety decreasing
Seems self-conscious
Anger issues
Moving through grief
Lack of focus/organiz.
Seems more secure
More self-confident
Increase in motivation
Defeating self-talk
Better self-care ( ADLs)
Difficulty breaking patterns
Establishing better boundaries
Other
Explain (Sub/ Obj)
*
Socialization
Social Interaction
*
Able to complete financial transaction independently
Able to complete financial transaction with verbal prompts
Needs physical demonstration or assistance completing financial transactions
Able to communicate needs and wants independently
Able to communicate needs and wants with verbal prompts
Needs physical demonstration or assistance to communicate needs and wants
Able to effectively regulate emotions
Able to effectively regulate emotions with verbal prompts.
Unable to effectively regulate emotions without staff assistance
Able to navigate through community independently
Able to navigate through community with verbal prompts and instructions
Unable to navigate through community without staff assistance
Able to problem solve independently
Able to problem solve independently with verbal prompts
Unable to problem solve without staff assistance
Other
Additional Notes
*
Drop Off Location
Where did you leave the client?
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Staff name
*
(first AND last)
Client Signature
*
Submit
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