Family Support Services Verification Log

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Wraparound Milwaukee
Enrollee/Client Name:
Service Month/Year:
Family Support Services Verification Log
_______________________________________
**USE OF THIS LOG FOR FAMILY SUPPORT SERVICES ONLY**
ID #
):
(if applicable per the agency
 
Service Code (check one) :
5521/H2021Tutoring
5524/H2021 Mentoring
Agency Name:  
5522/S5110 Parent Assistance
Other
(Identify service code and name of service):
_____________________________________________________________________
Provider Name: 
Date
Relationship to Service Recipient
Service Recipient /
Actual Session (face-to-face) Time
Signature of Service Recipient
Service
(Indicate relationship if it’s not the enrollee/ client
(must indicate a.m. or p.m.)
Recipient
Relationship to Enrollee
that has signed)
Session Date
Signed
(if applicable)
Session
Session
Today’s Date:
Start Time
End Time
*SAMPLE*
10:06a.m.
11:42a.m.
John Smith
John Smith
Total Units:
1.6
Self
03/04/14
03/04/2014
Session
Session
Today’s Date:
Start Time
End Time
Total Units:
Today’s Date:
Session
Session
Start Time
End Time
Total Units:
Today’s Date:
Session
Session
Start Time
End Time
Total Units:
Today’s Date:
Session
Session
Start Time
End Time
Total Units:
Today’s Date:
Session
Session
Start Time
End Time
Total Units:
Today’s Date:
Session
Session
Start Time
End Time
Total Units:
1-6 minutes = 0.1 units
25-30 minutes = 0.5 units
49-54 minutes = 0.9 units
NOTE: Having the service recipient pre-sign the Log is fraudulent behavior and may be grounds for termination from
7-12 minutes = 0.2 units
31-36 minutes = 0.6 units
55- 60 minutes = 1.0 units
any/all County Provider Networks & may prohibit any future contractual arrangements with the County.
13- 18 minutes = 0.3 units
37-42 minutes = 0.7 units
19-24 minutes = 0.4 units
43-48 minutes = 0.8 units
WRAPAROUND MILWAUKEE – Parent Assistance Policy - ATTACHMENT #5
H/CATC/QA Share/Family Support Signature Log
6/15/15

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