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Office of Mental Health

Home and Community Based Services Waiver Group Progress Notes

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Complete all fields:

A) Client’s name:

B) Client ID #:

C) Client’s date of birth:

D) Contact Date:

E) Start Time:

F) End Time:

G) Duration:

H) Check Waiver group service type: RS ____ SB ____ FSS ____:

I) This note is written for (check all that apply):

Waiver child: ______

Waiver child’s parent(s)/primary caregiver(s) _________

Names: ______________________________________________________________

Waiver child’s sibling ______ Sibling name(s): ______________________

_________________________________________________________________

J) Indicate participant to worker ratio for the group: ________

1. Identify goal number(s) and objective letter(s) that apply to this group contact: ________________________

2. Flexible Service Dollars: Amount spent: $________
Purpose of expenditure (on what was the money spent):

3. Summarize the contact for the Waiver child and/or each of his/her siblings and/or caregivers including a description for each of progress towards the Waiver child’s identified goal and objective:

4. Signature: Title: Date of Entry:

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.