Individual: _________________________________
FLP Name: _________________________________
Date:
Incidents:
Dr. Appointments:
Therapy Visits:
Morning Narrative: 12:00 am - ____am
Afternoon Narrative: ____pm - ____ pm
Evening Narrative: ____ pm - 11:59 pm
Please check below that apply:
□ Bathing:
___ □ Oral Hygiene:
___ □ Grooming:
___ □ Breakfast:
___ □ Ate/Packed Lunch:
___
Level
Level
Level
Level
Level
□ Asst. w/Meds:
___ Day Program- Yes___ No___□ Ate Dinner:
___
Level
Level
□ Cleaned Room:
___ Up During the Night: Yes___ No___ □ Did Laundry:
___
Level
Level
Daily Outings/Activities-__________________________________________________________________________________
Family Living Signature:
Date:
Incidents:
Dr. Appointments:
Therapy Visits:
Morning Narrative: 12:00 am - ____am
Afternoon Narrative: ____pm - ____ pm
Evening Narrative: ____ pm - 11:59 pm
Please check below that apply:
□ Bathing:
___ □ Oral Hygiene:
___ □ Grooming:
___ □ Breakfast:
___ □ Ate/Packed Lunch:
___
Level
Level
Level
Level
Level
□ Asst. w/Meds:
___ Day Program- Yes___ No___□ Ate Dinner:
___
Level
Level
□ Cleaned Room:
___ Up During the Night: Yes___ No___ □ Did Laundry:
___
Level
Level
Daily Outings/Activities-__________________________________________________________________________________
Family Living Signature:
Level
L egend:
V
( Verbal),
M d.
( Modeling),
I
( Independent),
P
( Physical),
T
( total
A ssistance),
R
( Refusal),
M s.
( Missed),
Y=
Y es,
N =No
DDSD
t emplate
f or
Family
L iving