Comments: (including Psychiatric services but not limited to: nursing, psychiatry services, therapy/counseling, medication management or Yes No psychiatric services) Comments: Residential supports (including but not limited to: 24 hour, Foster Care, Supported Living, Paid In-Home, family, Yes No friends/advocates/other, or other residential supports) Comments: Community supports (including but not limited to: family, employment, community inclusion, non-medical transportation, Yes No friends, advocates, or community supports) Comments: Part III: Case manager’s certification CDDP/Brokerage: Services coordinator Personal agent Other: By signing below, I confirm that: I have completed this evaluation in a face-to-face meeting; I have reviewed the notice of rights with the individual and his or her guardian (if applicable); and I have informed the individual of his or her freedom of choice and the to choose a qualified provider, and to accept or deny services. manager Signature Date (mm - dd - yy) Case - - Notes, etc. (include date of evaluation if different from signature date): Part IV: Individual’s choice
Comments: Psychiatric services (including but not limited to: nursing, psychiatry services, therapy/counseling, medication management or psychiatric services) Yes No Comments: Residential supports (including but not limited to: 24 hour, Foster Care, Supported Living, Paid In-Home, family, friends/advocates/other, or other residential supports) Yes No Comments: Community supports (including but not limited to: family, employment, community inclusion, non-medical transportation, friends, advocates, or community supports) Yes No Comments: Part III: Case manager’s certification CDDP/Brokerage: Case manager Services coordinator Personal agent Other: By signing below, I confirm that: I have completed this evaluation in a face-to-face meeting; I have reviewed the notice of rights with the individual and his or her guardian (if applicable); and I have informed the individual of his or her freedom of choice and the to choose a qualified provider, and to accept or deny services. Signature Date (mm - dd - yy) - - Notes, etc. (include date of evaluation if different from signature date): Part IV: Individual’s choice
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