176x Filetype PPTX File size 1.42 MB Source: www.masd.net
Personal Information Sheet Name __________________________________________Grad. Date _________________ Address _____________________________________________________________________ F M City, State, Zip code ________________________________________________________ Birthdate ________________________________ Age ___________ Sex Parents/Guardian Name ________________________________________________ _____________ Is student conserved yes no Phone Number ____________________________ SS # _________ _______ _________ Address if different than above High School Attended ___________________________ Yr. Graduated _________ _________________________________________ ____________________________________________________________________________ _ Medical Information: Phone/Cell Number _____________________________________________________ Mark all that apply Glasses Allergies ___________________________ Seizures Illnesses ___________________________ Medications – List ______________________________________________________ Primary Diagnosis _________________________________________________________ Secondary Diagnosis ______________________________________________________ Parent/Guardian Assessment 1. What chores or responsibilities does your student have at home? ______________________________________________________________________________ _ ______________________________________________________________________________ _ 2. What tasks would you like your student to be able to do at home? ______________________________________________________________________________ _ ______________________________________________________________________________ _ Group home 3. After graduation from ABLE, what do you think your students Other _____________________ living situation will be? At home Apartment with support Social skills Sex education 4. In which of the following areas of independence do you think your student needs help in: Organizational skills Household management Clothing care Self-advocacy Consumer Case Health/First aid Meal preparation Recreation/Leisure Nutrition Other _____________________ Community awareness Hygiene Transportation Safety 5. What leisure or recreational activities does your student do alone? _______________________________________________________________________ ______________________________________________________________________________ _ 6. What leisure/recreational activities does your student do with family? ______________________________________________________________________ ______________________________________________________________________________ _ 7. What leisure/recreational activities does your student participate in with friends? ____________________________________________________________ ______________________________________________________________________________ _ 8. What leisure/recreational activities would you like to see your student participate in? ____________________________________________________ ______________________________________________________________________________ _ 9. Does your student transition well from one thing to another? _____ Have there been any problems? __________________________________________ ______________________________________________________________________________ _ 10.What agencies currently provide service for your student?________ ______________________________________________________________________________ _ Supported employment 11. What would you like the school to do to assist you with the Day program planning of your students living, working and educational needs Home prior to graduation? _______________________________________________________ ______________________________________________________________________________ _ ______________________________________________________________________________ _ 12. Where do you see your student after graduating? Further education Full time employment Part time employment Personal Assessment 1. What chores or responsibilities do you have at home? ______________________________________________________________________________ _ ______________________________________________________________________________ _ 2. What tasks would you like to be able to do at home? ______________________________________________________________________________ _ ______________________________________________________________________________ _ Group home Other _____________________ 3. After graduation, what do you think your living situation will be? At home Independent Living Social skills Sex education 4. In which of the following areas of independence do you think you need help in: Organizational skills Household management Clothing care Self-advocacy Consumer Case Health/First aid Meal preparation Recreation/Leisure Nutrition Other _____________________ Community awareness Hygiene Transportation Safety 5. What leisure or recreational activities do you do when you’re alone? _______________________________________________________________________ ______________________________________________________________________________ _ 6. What leisure/recreational activities do you do with your family? ______________________________________________________________________________ _ ______________________________________________________________________________ _ 7. What leisure/recreational activities do you participate in with your friends? _______________________________________________________________ ______________________________________________________________________________ _ 8. What leisure/recreational activities would you like to see yourself participating in? ___________________________________________________________ ______________________________________________________________________________ _ 9. Do you transition well from one activity to another? _______ Have there been any problems? ________________________________________________ ______________________________________________________________________________ _ 10.What agencies currently provide service to you?___________________ ______________________________________________________________________________ _ Supported employment 11. What would you like the school to do to assist you with your Day program living, working and educational needs prior to graduating? Home ______________________________________________________________________________ _ ______________________________________________________________________________ _ ______________________________________________________________________________ _ 12. Where do you see yourself after graduating? Further education Full time employment Part time employment
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