DAILY SERVICE NOTE
Provider’s Name: Personal Touch Professional Services Il Individual Name: Jack Weckerly DOB: 10/16/1975 MCI: 002790492 W Code (s): W5996 Service Location Address: 6603 N Gratz St, Philadelphia, 19126 Service Delivered: CPS Unit of Service: 15min
Date :
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Date of Service:
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Month
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Year
Date
Please indicate the hours worked:
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8am-12pm
12pm-4pm
Other
Other: If hours worked are different from hours listed above. Please document here
Type of Activities: Please select all that apply:
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Promoting a spirit of personal reliance and contribution to the community
Developing mutual support and community connection
Developing social networks and connections within local communities
Planning and coordinating of the daily/weekly schedule for CPS with the individual
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Outcome Phase: Community Integration
Goal: Jack will participate in a community outing of his choice at least once a week as he tolerates. Please select all that apply:
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Community Walk
Community Store
Community Center/Park
Barbershop
Mall
Restaurant
Shopping
Volunteer
Religious Institution
Movies
Bowling
Gym
Visited Family Member or Friend
Other
Skills Checklist ( check all that applies )
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Communication Skills - Greeting others appropriately
Communication Skills - Asking for help or information
Communication Skills - Using polite language ("please," "thank you")
Communication Skills - Engaging in short conversations
Communication Skills - Expressing needs clearly
Social Interaction Skills - Taking turns
Social Interaction Skills - Sharing space with others
Social Interaction Skills - Participating in group activities
Social Interaction Skills - Respecting others’ belongings
Social Interaction Skills - Following social rules (quiet voice, staying seated, etc.)
Safety Awareness Skills - Following traffic signals / crosswalk rules
Safety Awareness Skills - Staying with the group
Safety Awareness Skills - Recognizing community signs
Safety Awareness Skills - Managing personal space
Safety Awareness Skills - Responding appropriately to unexpected events
Money & Decision-Making Skills - Comparing prices
Money & Decision-Making Skills - Budgeting or planning purchases
Money & Decision-Making Skills - Paying for items
Money & Decision-Making Skills - Choosing items independently
Money & Decision-Making Skills - Making decisions (movie choice, snack choice, activity choice)
Community Navigation Skills - Identifying locations (store sections, movie theater areas, community center rooms)
Community Navigation Skills - Following posted signs
Community Navigation Skills - Understanding community routines (checkout, ticketing, class sign-in)
Community Navigation Skills - Navigating crowds calmly
Emotional & Coping Skills - Managing noise or sensory input
Emotional & Coping Skills - Staying calm in crowded environments
Emotional & Coping Skills - Using coping strategies when overwhelmed
Emotional & Coping Skills - Handling changes in routine
Emotional & Coping Skills - Demonstrating patience (waiting in line, waiting for turn)
Problem-Solving Skills - Asking what to do if an item is unavailable
Problem-Solving Skills - Adjusting to schedule or plan changes
Problem-Solving Skills - Resolving small conflicts appropriately
Problem-Solving Skills - Identifying solutions independently
Participation & Independence Skills - Joining activities at the community center
Participation & Independence Skills - Following multi-step directions
Participation & Independence Skills - Completing tasks with minimal prompts
Participation & Independence Skills - Demonstrating independence in public settings
Did Jack choose his activity ?
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Yes
No
Place activity occurred ( For Example Walmart or Planet Fitness)
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Location the activity occurred ( For example on Cheltenham Ave)
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Please indicate whether the Goal was Completed/Not Completed:
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Yes
No
Goal Completed
If the goal was not completed today, explain why:
Was transportation provided to the outing even if it was ?
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Yes
No
If your answer is "No," please explain the reason below:
Provide a summary of the shift also document any issues or appointments below: Also note if the goal was completed along with supports given and progress. If not completed, explain why.
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List barriers & conditions necessary for community inclusion. Please Select all that apply:
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Unable to express needs adequately
Low Motivation
Communication Barrrier
Other
Strengths & Skills: Please Select all that apply.
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Self- motivated
Good Leadership skills
Able to express needs
Able to follow directions
Easy to make friends
Other
DSP Printed First and Last Name:
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Title ( for Example DSP):
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Date:
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Signature
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Submit
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