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PRELIMINARY SERVICE PLAN

[within 30 days of admission]

Participant's Name: _____________________________________________________

Admission date: __________ DOB: ___________

NEEDS ASSESSMENT:
Psycho-social status:

Awareness level: alert_____ confused_____ depressed_____ other_

Personal care needs:


______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Socialization needs / preferences:


_____________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Functional status:
Ambulation and Transfers
Transfers: independent _____ cane/walker _____ w/c _____
assist of 1 _____ assist of 2______

Activities of daily living: independent _____ assist of 1 _____ assist of 2 ___________

Physical status:
______________________________________________________________________________
______________________________________________________________________________

Katie Adult Day Center Policies and Procedures Manual 10-009.16


PRIMARY SERVICE PLAN:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

INITIAL PLAN of CARE:


______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

ATTENDANCE:
Which days do you want your loved one to attend the center?

Monday Tuesday Wednesday Thursday Friday

Transportation Arrangements: (please circle)

Metro Mobility ADS center van Family Escort Other

DIETARY: Does your loved one have any dietary restrictions? If so, please describe how to
assist.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Food portion sizes: S M L Diabetic Low Salt Low Cal Cut up foods

CAREGIVER ROLE:
Role of caregiver in service plan:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Katie Adult Day Center Policies and Procedures Manual 10-009.16


Participant will be involved in all scheduled day program-activities upon admission excluding:

______________________________________________________________________________
______________________________________________________________________________

Participant/caregiver signature:____________________________________________________

Date:___________________________

Staff signature:_________________________________________________________________

Date:___________________________

Katie Adult Day Center Policies and Procedures Manual 10-009.16

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